Nurs 226 Final
A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurse's station? a) sustained a head injury and is having periods of confusion b) reports severe migraine headache c) suspected diagnosis of TB d0 history of atrial fibrillation and is on continuous ECG monitoring
a
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? a) secure the restraints using a quick release tie b) ensure four fingers fit under the restraints to prevent constriction c) secure the restraints to the lowest bar on the side rail d) anticipate removing the restraints every 4 hr
a
A nurse is caring for a client who is to receive a full liquid diet due to dysphagia. Which of the following nursing actions is the highest priority? a) add thickener to liquids b) educate client about acceptable liquids c) perform a calorie count of consumed liquids d) offer high protein liquid supplement
a
A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? a) when the client has the urge to defecate b) every 2 hr while the client is awake c) immediately before the client has a meal d) after the client feels abdominal cramping
a
A nurse is performing trach care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? a) suction 2/3 times with a 60 second pause between passas b) perform chest physiotherapy prior to suctioning c) lubricate the suction catheter tip with sterile saline d) hyperventilate the client to 100% oxygen prior to suctioning
a
A nurse is planning care for an older client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a) use a transfer device to lift the client up in bed b) apply cornstarch to keep sensitive skin areas dry c) massage the skin over the client's bony prominences d) elevate the head of the bed no more than 45 degrees
a
Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? a) nurse who delegated the task b) LPN working with the NAP c) unit nurse manager d) charge nurse for the shift
a
A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? Select all that apply. a) excessive laxative use b) ignoring the urge to defecate c) inadequate fluid intake d) increased fiber in the diet e) increased activity
a,b,c
A nurse provides a back massage as palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? Select all that apply. a) shoulders droop b) facial muscles relax c) respiratory rate increases d) pulse is within the expected range e) client draws his legs up into a fetal position
a,b,c
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? Select all that apply. a) report of feeling pressure b) tenderness over the symphysis pubis c) distended bladder d) voiding 30mL frequently e) dysuria
a,b,c,d
A client receives wrong medication. The nurse who made the medication error should take which of the following actions first? a) call the provider b) asses the client b) notify the nurse manager d) complete an incident report
b
A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? a) "I'll urinate a little then stop" b) "I'll use the cleansing wipe from front to back" c) "I'll clean the inside of the container with a wipe" d) "I'll use each cleansing wipe twice"
b
A nurse is assessing a client and discovers that infusion pump with client's total parenteral nutrition solution is not infusing. The nurse should monitor the client for V conditions? a) excessive thirst and urination b) shakiness and diaphoresis c) fever and chills d) hypertension and crackles
b
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? a) place the wheelchair at a 90 degree angle to the bed b) lock the wheels of the bed and the wheelchair c) acquire the help of several people to life the client d) elevate the bed to a position of comfort for the nurse
b
A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? a) steatorrhea b) blood c) bacteria d) parasites
b
A nurse is caring for a client who has active pulmonary TB. The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest xray? a) ask the xray tech to come to the client's room to obtain a portable xray b) have the client wear a mask c) notify the xray department that the client requires airborne precautions d) wear a filtration mask and gloves during transport
b
A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? a) 6 b)4 c)7 d) 8
b
A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on Which of the following methods of determining the intensity of the client's pain? a) vitals b) self report of pain severity c) visual observation for nonverbal signs of pain d) nature and invasiveness of the surgical procedure
b
A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? a) call the family and ask them to stay with the client b) move the client to a room closer to the nurse's station c) apply wrist and leg restraints to the client d) administer medication to sedate the client
b
A nurse is planning care for a client who has a decreased LOC. The client is receiving continuous enteral feedings via gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? a) observe client's respiratory status b) elevate the head of the bed 30-45 degrees c) monitor intake and output every 8 hr d) check residual volume every 4 hr
b
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? a) adjust the water temperature to feel hot b) apply 4-5 mL of liquid soap to the hands c) hold the hands higher than the elbows d) rub hands and arms dry
b
A nurse is receiving change of shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? a) critically analyze client data to determine priorities b) collect and organize client data c) set client centered, measurable and realistic goals d) determine effectiveness of interventions
b
A nurse is teaching a client who reports insomnia about prompting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a) "I will walk briskly for 30 min before bedtime" b) "I will no longer have a glass of wine before bedtime" C) "I will have a cup of hot cocoa immediately before bedtime" D) "I will do my muscle relaxation techniques each afternoon"
b
A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: a) maturational b) situational c) sociocultural d) posttraumatic
b
A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? a) hypotension b) numbness c) shivering d) reduced blood viscosity
c
A nurse is admitting a client who is arriving back from the unit from the PACU following hip arthroplasty. Which of the following tasks should the nurse assign to the AP? a) obtain vitals b) determine if the client is in need of pain med c) record the amount of urine in the catheter drainage bag d) instruct the client on the use of the incentive spirometer
c
A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sound sin the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of Which of the following conditions? a) upper respiratory infection b) pulmonary edema c) atelectasis d) delayed gastric emptying
c
A nurse is caring for a client who has MRSA in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? a) wear N95 respirator mask b) wear sterile gloves c) wear clean gloves d) wear protective eyewear
c
A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? a) lemon sherbet b) plain yougurt c) cranberry juice d) carrot juice
c
A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? a) placing a sterile dressing 5cm from the border b) holding a sterile item at just above waist level c) opening a sterile package over the middle of the sterile field d) opening the sterile tray by first unfolding the flap farthest from his body
c
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? a) use a stiff toothbrush to clean the client's teeth b) use the thumb and index finger to keep the client's mouth open c) turn the client on his side before starting oral care d) apply petroleum jelly to the client's lips after oral care
c
The nurse is assessing a client with dark skin for the presence of a stage 1 pressure ulcer (injury). Which is the best approach to making this assessment? a)Use a fluorescent light source to assess the skin b)Inspect the skin only when the Braden score is above 12 c)Look for skin color that is darker than the surrounding tissue d)Avoid touching the skin during inspection
c
What is the correct method for turning an adult patient brought to the ER with a suspected spinal cord injury? a)Ask the patient to assist with the turn by holding the siderails of the bed b)Place a draw sheet under the patient to assist with turning c)Request help from another nurse to perform logrolling technique d)Use a mechanical lift for safe turning and protecting the nurse's back
c
Which patient has an naturally acquired active immunity? a)The adult who received immunizations b)The infant whose immunity was transferred from the mother to the infant. c)The child is recovering from a childhood disease that conferred immunity. d)The adult who received gamma globulin after exposure to Hepatitis.
c
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? a) creatine kinase b) troponin c) total bilirubin d) albumin
d
A nurse is caring for a client who ahs fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? a) "There were no injuries sustained" b) "A incident report was completed" c) "An incident report was forwarded to risk management" d) "The provider was notified"
d
A nurse is caring for a client who ahs returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? a) administer oxygen at 1L/min b) administer prescribed analgesic med c) encourage coughing and deep brathing d) raise the head of the bed
d
A nurse is caring for a client who has an indwelling urinary catheter and notes blood tinged urine in the bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? a) pernicious anemia b) dehydration c) prostate enlargement d) bladder infection
d
A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? a) trochanter roll b) sheepskin heel pad c) abduction pillow d) footboard
d
A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? a) use sterile swab to obtain the specimen b) place the specimen in a sterile container c) label the paper bag in which specimen container is placed d) send specimen container immediately to the lab
d
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of he following purposes? a) confirm the placement of the NG tube b) remove gastric acid that might cause dyspepsia c) determine client's electrolyte balance d) identify delayed gastric emptying
d
A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the AP while the client is sleeping should prompt the nurse to intervene? a) closes the door to the client's room b) measures the client's vital signs routinely c) asks group of nurses in the hall to speak quietly d) flushes the client's toilet after emptying the urinary catheter's drainage bag
d
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? a) mix 3 meds together prior to administering b) dilute each med with 10 mL of tap water c) maintain the head of the bed in a flat position for 30 min following med admin d) flush the NG feeding tube with 30 mL of water immediately following med admin
d
A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? a) one nurse lifting as the client pushes with feet b) two nurses lifting the client under the shoulders c) one nurse lifting the client's legs as the client uses a trapeze bar d) two nurses using a friction reducing device
d
A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? a) contract the pelvic muscles b) take a sip of water c) exhale slowly d) bear down
d
The nurse must transfer a dependent patient from a bed to a gurney. Which action by the nurse will be safest for the patient and nurse? a) adjust bed height b) avoid movements that twist spine c) keet pt close to nurse's body when lifting d) obtain an appropriate mechanical life device
d
A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? Select all that apply. a) bathtub with rails b) electronic cords behind the furniture c) raised toilet seats d) water heater temperature 130 F e) throw rugs
d,e
A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (Select all that apply) a) poor wound healing b) dry hair c) blood pressure in 130/80 d) weak hand grips e( impaired coordination
a,b,d,e
The nurse has just completed wound care on her patient who has a large abdominal wound. What should the nurse do soon after this is completed? Select all that apply. a)Assess the patient's response to the procedure b)Teach the patient about the procedure c)Document the procedure in the nursing progress notes d)Ask the patient to assist in the wound care at the next scheduled dressing change
a,c
Based only on Maslow's Hierarchy of Needs, which nursing diagnosis should have the highest priority? a) self care deficit b) risk for aspiration c) impaired physical mobility d) functional urinary incontinence
b
When preparing a sterile field, which condition indicates to the nurse the field is at risk for contamination? a)The dressing is laying 3 inches away from the border of the sterile field b)An opened sterile package is placed into the middle of the sterile field c)A sterile item is held above waist level and in eye sight d)Clean gloves are used to pore sterile saline into the sterile cup
b
Which of the following is an example of a problem that nurses can treat independently? a) hemorrhage b) nausea c) fracture d) infection
b
Which statement related to prioritizing patient problems is most accurate? a)Nurses must resolve one problem before addressing another problem. b)Nurses prioritize problems in order of urgency. c)Actual problem always take priority over risk problems. d)Nurses give the highest priority to problems that the patient thinks are most important.
B
A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? a) determine airway adequacy hourly as needed b) administer oxygen as needed c) monitor arterial blood gas values d) place the client in high fowler's position
a
A nurse is assess the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following? a) presence of associated symptoms b) location of the pain c) pain quality d) aggravating and relieving factors
a
A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2000mL/day. The client asks the nurse how to determine the appropriate amount of fluids he is allowed. Which of the following statement is an appropriate response by the nurse? a)"Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink" b)"Each glass contains 8 ounces. There are 30 milliliters per ounce so you can have a total of 8 glasses or cups of fluid each day" c)"This is the same as 2 quarts or about the same as two pots of coffee" d)" Take sips of water or ice chips so you will not take in too much fluid"
a
A nurse is teaching a patient how to administer medications through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? a) "Flush the tube before and after each medication" b) "Administer your medications with your enteral feeding" c) "Administer tablets through teh tube slowly" d) "Mix all the crushed medication prior to dissolving in water
a
A nurse prepares an injection of morphine (Duramorph) to administer to a patient who reports pain. Prior to administering the medication, the nurse is called to another room to assist another patient onto a bedpan. She asks the second nurse to give the injection. Which of the following actions should the second nurse take? a) Offer to assist the patient needing the bedpan. b) Administer the injection prepared by the other nurse. c) Prepare another syringe and administer the injection. d) Tell the patient needing the bedpan she will have to wait for her nurse.
a
A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? a)Ask a colleague for help because the nurse cannot safely perform the procedure alone. b)Gather the equipment and prepare it before informing the client about the procedure. c)Obtain an order to restrain the client before inserting the urinary catheter. d)Inform the primary provider that the nurse cannot perform the procedure because the client is confused
a
Post-op, the patient is receiving morphine via the patient controlled analgesia pump (PCA). The nurse finds the patient drowsy, with Temp 97.2 F, pulse 52, RR 11, BP 101/58 and pulse ox 93% on 2L of oxygen. Which action should the nurse take first? a) attempt to arouse pt b) contact hcp c) check PCA pump setting an history d) document findings
a
TPN is prescribed for a patient with Chron's disease. What indicates to the nurse that the TPN has been effective? a) has met nutritional needs b) is not in metabolic acidosis c) is hydrated d) is in negative nitrogen balance
a
What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: a) judgemental b) too complex c) legally questionable d) without supportive data
a
Which action by the nurse most likely represents a situation of assault? a) In the emergency room, the patient is intoxicated and verbally abusive. The nurse informs the patient restraints will be used if the behavior doesn't cease. b)The patient is in labor and has not received any medications for pain. The patient continues to refuse any pain medications. The nurse administers the pain medication ordered. c)The patient is planning to leave the unit against medical advice. The nurse states it is not in the patient's best interest given the medical condition and will call security if needed d)The patient's church pastor calls the unit regarding the patient's condition. The nurse provides the clergyman with an update on the patient's condition.
a
Which of the following describes the difference between dehiscence and evisceration? a)With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b)Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent c)Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d)Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.
a
A nurse is caring for a client with dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) a)Have suction equipment available for use b)Use thickened liquids c)Place food on the client's unaffected side of her mouth d)Assign an assistive personnel to feed the client slowly e)Teach the client to swallow with her neck flexed
a,b,c,e
A school nurse is teaching a group of students how to read food labels. Which of the following should be included in the teaching? (select all that apply) a) total carbohydrates b) total fat c) calories d) magnesium e) dietary fiber
a,b,c,e
A nurse is assessing a client who has an acute respiratory infection that places her at risk for hypoxemia. Which of the following findings are early indicators that should alert the nurse that the patient is developing hypoxemia? Select all that apply a) restlessness b) tachypnea c) brady cardia d) confusion e)pallor
a,b,d,e
A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? (select all that apply) a) nail polish b) inadequate peripheral circulation c) hypothermia d) increased hgb level e) edema
a,b,e
The client was found lying on the floor next to the bed. Once urgent care is provided, the nurse completes an incident report. Which statements (in chart) would be inappropriate to include in the report. Select all that apply. 1. The client fell out of bed 2. No bruises or injuries are noted on the client 3. The client apparently climbed over the side rails when the nurse was out of the room 4. The physician was notified that the client was found lying on the floor next to the bed 5. The client is alert and oriented and stated that he needed to go to the bathroom and didn't want to bother the nurse 6. Vital signs are temperature 98.6, pulse 78 regular, respiration 16, BP 118/78 a)1 b)2 c)3 d)4 e)5 f)6
a,c
A nurse is teaching a client about high-fiber foods that can assist in lowering LDL. Which of the following foods should be included in the teaching? (Select all that apply) a) beans b) cheese c) whole grains d) broccoli e) yogurt
a,c,d
A nurse in a provider's office is caring for a patient who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following questions should the nurse ask when collecting data about the patient's difficulty sleeping. (Select all that apply) a)Does your lack of sleep interfere with your ability to function during the day? b)Do you feel confused in the late afternoon? c)Do you drink coffee tea or other caffeinated drinks? If so how many cups per day? d)Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? e)Tell me about your personal stress you are experiencing
a,c,d,e
A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Select all that apply. a)Developing culturally appropriate outcomes b)Using the standardized outcomes on the clinical pathway c)Choosing the best outcome for the patient regardless of the cost d)Involving the patient and family in formulating the outcomes
a,d
Which are complications of bed rest? Select all that apply. a) extremity contractures b) decreased dependency c) diarrhea d) pneumonia e) pressure ulcers f) thrombi g) urinary calculi
a,d,e,f,g
A nurse is caring for a client who has Alzheimer's Disease and falls frequently. Which of the following actions should the nurse take first to keep the client safe? a)Keep the call light near the client. b)Place client in a room close to the nurses' station c)Encourage client to ask for assistance d)Remind client to walk with someone for support
b
A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to a)Massage both legs firmly with lotion prior to applying the stockings b)Apply the stockings in the morning upon awakening and before getting out of bed c)Roll the stockings down to the knees if they will not stay up on the thighs. d)Remove the stockings while out of bed for one hour, four times a day to allow the legs to rest.
b
A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first? a) observe client weight b) assist client into high fowlers position c) auscultate lung sounds d) check oxygen saturation with pulse oximeter
b
A nurse is caring for a patient who is having difficulty breathing. The client is lying in bed and already receiving oxygen via nasal cannula. Which of the following interventions is the nurse's priority? a) increase oxygen b) assist client to fowlers position c) promote removal of pulmonary secretions d)obtain a specimen for ABG
b
A nurse is caring for an older adult client in an extended care facility. Which of the following indicates the client has a stool impaction causing a large intestine obstruction? a)The client reports he had a bowel movement yesterday b)The client is having small, frequent liquid stools c)The client is flatulent d)The client indicates he vomited once this morning
b
A nurse is caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals? a)A client who has decreased vision b)A client who has Parkinson's disease c)A client who has poor dentition d)A client who has anorexia
b
A nurse is completing an assessment of a client who is a first generation immigrant to the U.S. Which of the following questions should the nurse consider asking to understand the client's culture-based nutrition habits? a)"What type of afternoon snacks do you consume?" b)"What type of meal do you prepare for a holiday?" c)"What time of day do you eat breakfast?" d)"What cooking utensils are used in food preparation?"
b
A nurse is reviewing the laboratory findings for urinalysis (UA) of a client who reports urgency and nocturia. Which of the following findings should the nurse report to the provider? a) positive for casts b) positive for leukocyte esterase c) positive for epithelial cells d) positive for crystals
b
A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires clarification? a)"I should wash my hands after blowing my nose to prevent spreading the virus" b)"I need to avoid drinking fluids if I develop symptoms" c)"I need a flu shot every year because of the different flu strains" d)" I should sneeze into my elbow rather than my hands"
b
A nurse is working with a newly hired nurse who is administering medications to patients. Which of the following actions by the newly hired nurse indicates an understanding of medication error prevention? a) Taking all medications out of the unit-dose wrappers before entering the patient's room. b)Checking with the provider when a single dose requires administration of multiple tablets. c)Administering a medication, then looking up the usual dosage range. d)Relying on another nurse to clarify a medication prescription.
b
A patient admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft restraints. Which nursing action is most appropriate? a) Perform circulation checks to bilateral upper extremities each shift b) Attach the ties of the restraints to the bed frame c) Reevaluate the needs for restraints and document weekly d) Ensure the restraint prescription has been signed by the health care provider (HCP) within 72 hours
b
A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is: a)Administering a sleep aid b)Synchronizing the medication, treatment, and vital signs schedule c)Encouraging the patient to exercise immediately before sleep d)Discussing with the patient the benefits of beginning a long-term nighttime medication regimen
b
A patient using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA? a)Reassure the patient the pain will be relieved b)Document the patient's response to pain medication c)Instruct the patient to continue pressing the system's button whenever pain occurs d)Titrate pain medication until the patient is free from pain
b
The nurse is assessing a hospitalized older patient for the presence of pressure ulcers. The nurse notes that the patient has a 1" by 1" (3cm by 3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a)Stage I pressure ulcer b)Stage 2 pressure ulcer c)Stage 3 pressure ulcer d)Stage 4 pressure ulcer
b
The nurse is preparing to insert a Foley catheter for her patient. What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner? a)Call another nurse to assist with the procedure b)Gather all supplies and equipment before entering the patient room c)Instruct and explain the procedure to the patient d)Check the patient's schedule for the day for the most convenient time
b
The nurse is teaching the patient how to care for an ileostomy. The patient asks the nurse how long to wear the pouch before changing it. What should the nurse tell the patient? a)"The pouch is changed only when it leaks" b)"You can wear the pouch for about 4 to 7 days>" c)"You should change the pouch every evening before bedtime." d)"It depends on your activity level and your diet."
b
The nurse works with the respiratory therapist to administer a patient's breathing treatments. He reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of: a) delegation b) collaboration c) coordination of care d) supervision of care
b
Total parenteral nutrition (TPN) is prescribed for the patient who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? a) Administer TPN through a nasogastric or gastrostomy tube b) Handle TPN using strict aseptic technique c)Auscultate for the presence of bowel sounds prior to administration of TPN d)Designate a peripheral IV site for TPN administration
b
Which of the following examples includes both objective and subjective data? a)The patient's blood pressure reading is 132/68 mm Hg and heart rate is 88 beats/min. b)The patient's cholesterol is elevated, and he states he likes fried food. c)The patient states she has trouble sleeping and that she drinks coffee in the evening. d)The client states he gets frequent headaches and that he takes aspirin for the pain.
b
Which of the following nursing activities is most reflective of the evaluation phase of the nursing process? a)Administering pain medication prior to changing a complex wound dressing b)Obtaining patient's blood pressure 30 minutes after administering blood pressure medication c)Reporting that there have been three patient falls in the past month on the nursing unit d)Teaching the patient how to perform daily Accu-Cheks for blood sugar readings
b
While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a) sanguineous b) serosanguineous c) serous d) purosanguineous
b
You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: a) an increased appetite b) an increased heart rate c) a decrease in perspiration d) a decrease in respiratory rate
b
The nurse should perform passive range-of-motion (ROM) exercises on which patients? Select all that apply a)Has septic joints b)Has temporary loss of consciousness c)Is unconscious d)Has plantar flexion of the foot e)Has supination of the hand
b,c
A nurse is providing teaching to an older adult patient to promote adherence with medication administration. Which of the following instructions should the nurse include? (Select all that apply) a)Adjust the dose according to daily weight. b)Place pills in daily pill holders. c)Provide liquid forms if the patient has difficulty swallowing pills. d)Ask a relative/friend to assist periodically e)Request child-guard caps on medication containers.
b,c,d
What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply. a) change the catheter daily b) provide perineal care at least once a day c) maintain a closed drainage system d) encourage the patient to drink 3000 mL fluids daily e) recommend health care provider prescribe antibiotics
b,c,d
When teaching the patient with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the patient to report which symptoms to the health care provider (HCP)? Select all that apply. a)Cloudy urine for the first few days b)Blood in the urine c)Rash d)Mild nausea e)Fever above 100 degrees F (37.8 degrees C) f)Urinating every 3 to 4 hours
b,c,e
A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension? (Select all that apply) a)Drinking 8oz of nonfat milk daily b)Eating popcorn at the movie theater c)Walking 1 mile daily at 12 min/mile pace d)Consuming 36 oz of beer daily e)Getting a massage once a week
b,d
A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: a) adding a daytime nap b) allowing the child to sleep longer in the morning c) maintaining the child's home sleep routine d) offering the child a bedtime snack
c
A nurse is caring for a client who displays signs of Stage 3 Parkinson's disease. Which of the following actions should the nurse include in the plan of care? a)Recommend a community support group b)Integrate a daily exercise program c)Provide a walker for ambulation d)Consultation with a dietitian
c
A nurse is caring for a patient with a Foley catheter. What should the nurse do to reduce the risk of infection? a) clean perineum with peroxide after each void b) decrease oral fluids c) empty the foley bag every 4-8 hours d) open bag and foley system to check for kinks
c
A nurse is completing discharge teaching with a client who is 3 days post operative for a transverse colostomy. Which of the following should be included in the teaching? a)Mucus will be present in stool for 5 to 7 days after surgery b)Expect 500 to 1,000 mL of semi-liquid stool after 2 weeks c)Stoma should be pink and moist d)Change the ostomy bag when it is ¾ full
c
A nurse is instructing an assistive personnel in caring for a client who has a low platelet count and needs vital signs taken. Which of the following statements contain the correct instructions in this situation? a)Count the patient's radial pulse for 60 seconds b)Count the respiratory rate and tell the patient you are doing so c)Do not take the patient's temperature rectally d)Let the patient rest in between each vital sign for 5 minutes.
c
A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to: a)Avoid returning to the use of an ostomy appliance if he becomes ill. b)Call the primary care provider if the stoma becomes pale, dusky, or black. c)Irrigate the stoma to produce a bowel movement on a schedule. d)Limit the intake of gas-forming foods such as cabbage, onions, and fish
c
A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Which of the following should be included in the instructions? a)Apply petroleum jelly around the nares b)Assure the patient and their family that the patient can still smoke c)Check the position of the nasal cannula frequently d)Remove the nasal cannula during meal time
c
The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. It will be most important for the nurse to a) report this finding to the provider b) note this finding in the client's record c) revise the plan of care d) remove the nursing diagnosis from the plan
c
The nurse is caring for a patient with bacterial pneumonia. The effectiveness of the patient's oxygen therapy can be best determined by which indicator of oxygenation? a) absence of cyanosis b) patient's resp rate c) arterial blood gas values d) patient's level of consciousness
c
The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? a)Tell the charge nurse that the nurse is going to lunch b)Verify that the charge nurse has assigned someone to take care of the patient c)Give the charge nurse information about what care should be given while the nurse is at lunch d)Remind the charge nurse about the patient's history and current medicaitons
c
The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first? a)Gait unsteady, uses walker, needs 2-person assist with ambulation b)Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min c)Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale d)Verbalizes history of migraine headaches, eyes closed during assessment interview
c
The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery. It reads: Assist patient in bathing each morning. The nurse assesses the patient and notes that the patient is independent in bathing. What should the nurse do next? a)Assist with the bath as ordered b)Delegate the bath to the nursing assistant c)Discontinue the nursing order on the plan of care d)Collaborate with the nurse who originally wrote the order
c
Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? a)Bowel Obstruction related to recent abdominal surgery AMB: nausea, vomiting, and abdominal pain b)Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight c)Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area d)Caregiver Role Strain related to alienation from family and friends AMB 24-hour care responsibilities
c
Which of the following is an example of an active listening behavior? a) taking frequent notes b) asking for more details c) leaning toward the patient d) sitting comfortably with legs crossed
c
Which of the following is the best example of an outcome statement? The patient will: a)Use the incentive spirometer when awake b)Walk two times during day and evening shift c)Maintain oxygen saturation above 92% while performing ADLs each morning d)Tolerate 10 sets of range-of-motion exercises with physical therapy
c
Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? a)"Record how the patient's intake and output of fluids, please" b)"Take the patient's temperature, pulse, respirations, and blood pressure every 2 hours today." c)"Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)." d)"Assist the patient with all of her meals so she will take in more calories."
c
A nurse is assessing a client who is postoperative following a colon resection. Which of the following findings indicates that the client is ready to transition from NPO to oral intake? a) client report of hunger b) urinary output exceeding 30mL/hr c) decrease in incisional pain d) passage of flatus
d
A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit? a) moist skin b) distended neck veins c) increased urinary output d) tachycardia
d
A nurse is discussing foods that are high in Vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? a) tacos and rice b) hamburgers and fried potatoes c) ham and brussels sprouts d) eggs and fortified milk
d
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements made by the client indicates an understanding of the teaching? a)"I will place the adapter on my finger to read my blood oxygen saturation level." b)"I will lie on my back with my knees bent." c)" I will rest my hand over my abdomen to create resistance." d)" I will take in a deep breath and hold it before exhaling."
d
A nurse is obtaining a history from a client who has pain. The nurse's guiding principles throughout this process should be that a)Some clients exaggerate their pain level b)Pain must have an identifiable source to justify the use of opioids c)Objective data are essential in assessing painPain is whatever the client says it is d)
d
A nurse is preparing to feed a patient via NG tube. Which of the following is the nurse's highest priority before initiating the feeding? a)Check the feeding container for expiration b)Confirm the patient does not have diarrhea c)Make sure the client is alert and oriented d)Verify placement of the NG tube
d
A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write? a) collaborative b) interdependent c) dependent d) independent
d
A patient is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the patient to exert control over physiologic processes by which mechanism? a)Regulating the body processes through electrical control b)Shocking the patient when an undesirable response is elicited c)Monitoring the body processes for the therapist to interpret d)Translating the signals of body processes into observable forms
d
During meal time the nurse notices the patient's hands are holding the throat. Which patient situation requires immediate action by the nurse? a)The patient has a high-pitched inspiratory stridor b)The patient is talking and gagging c)The patient is coughing d)The patient is not making any sounds
d
During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as: a) cataplexy b) insomnia c) narcolepsy d) sleep apnea
d
The nurse is called to the patient's room by another nurse. When the second nurse arrives at the room, she discovers that a fire has occurred in the patient's waste basket. The first nurse has removed the patient from the room. What is the second's nurse next action? a) evacuate the unit b) extinguish the fire c) confine the fire d) activate the fire alarm
d
The nurse is planning the care of a frail, immobile, elderly patient. Which of the following is the best treatment or prevention to protect the patient's skin? a)Administer fluid boluses as directed by the healthcare provider b)Assisting the patient to sit in a chair three times a day c)Offering the patient six small meals a day d)Turning the patient at least every 2 hours
d
When coping becomes dysfunctional enough to require the client to be admitted to the hospital, the nurse expects that the client would be exhibiting what behaviors? a)Objective and rational problem solving b)Tension reduction activities and then problem solving c)Anger management strategies with no problem solving d)Minimal functioning with new problems developing
d
Which intervention should the nurse take first to promote the start of urination in a patient who is having difficulty voiding? a)Insert an intermittent, straight catheter b)Insert an indwelling urinary catheter c)Notify the provider immediately d)Pour warm water over the patient's perineum
d
Which of the following is the best example of the implementation phase of the nursing process? a)Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication. b)Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. c)Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom. d)Nurse inserts Foley catheter after reporting to physician patient's inability to void.
d
The nurse is reviewing hand hygiene with UAPs. Which statement by the UAP requires further instructions? a)"I will wash my hands before and after care and I wear gloves with each patient." b)"I wash my hands when they are visible soiled." c)"I will not wear artificial nails when providing care." d)"It is OK to use the alcohol based products outside of the patient's room when entering and leaving the area."
b
A nurse is caring for a client who has cancer pain. Which of the following is the most reliable indication of the client's pain? a) change in pulse b) facial expression of pain c) verbal report of pain d) massaging area of pain
c
A nurse is caring for a client who has cancer pain. Which of the following is the most reliable indicator of the client's pain? a) change in pulse rate b) facial expressions of pain c) verbal report of pain d) massaging an area of pain
c
A nurse is caring for an Asian client who has hypertension. Which of the traditional Asian dietary patterns places the client at risk for this condition? a)Incorporation of plant based foods in the diet b)Consumption of raw fruits c)Preparation of foods using sodium d)A focus on shellfish in the diet
c
A nurse is preparing to administer a medication to a patient. The medication was scheduled for administration at 0900. Which of the following are acceptable administration times for this medication? (Select all that apply) a) 0905 b) 0825 c) 1000 d) 0840 e) 0935
a,d
A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? a) nonrebreather mask b) venturi mask c) nasal cannula d) simple face mask
b
Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surger? a)Age over 75 years b)Poorly controlled diabetes c)History of one myocardial infarction d)Chronic peripheral vascular disease
b
Which mental status change may occur when a patient with pneumonia is first experiencing hypoxia? a) coma b) apathy c) irritability d) depression
c
Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with diarrhea? a) edema b) hypothyroidism c) pallor d)tenting
d
