NURS 2821 Exam 3 Practice Questions
A patient who is newly diagnosed with breast cancer states, "Although I am really scared about what is going to happen to me, I know my family will learn from this experience, and we will be stronger in the end." What term does the nurse use in the patient's 133medical record to describe the characteristic displayed in this statement? 1. Resiliency 2. End-of-life care 3. Family functioning 4. Family's culture
1
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.
1
The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? 1. Physical care technique 2. Activity of daily living 3. Indirect care measure 4. Lifesaving measure
1
What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization
1
Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need? 1. Patient obtains social support care related to caregiver stress 2. Fear related to open-heart surgery 3. Acute Pain related to splinting of incision 4. Impaired Family Coping related to insufficient caregiver support
1
A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether the patient feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse's ability to perform patient evaluation? (Select all that apply.) 1. Comparing patient response with previous response 2. Examining results of clinical data 3. Recognizing error 4. Self-reflection 5. Checking medical record for when IV was inserted.
1, 2
Which of the following statements correctly describe the evaluation process? (Select all that apply.) 1. Evaluation is an ongoing process. 2. Evaluation involves the gathering of data for recognizing errors or omissions in care. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is done only when a patient's condition changes.
1, 2, 3, 4
Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) 1. Checks scientific literature or policy and procedure 2. Determines whether additional assistance is needed 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure
1, 2, 3, 5
Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately
1, 2, 3, 5
A family consisting of a grandparent, two adults, and three school-age children just immigrated to the United States. They come to a community wellness center to establish health care. Which of the following questions does the nurse ask to assess the family's function? (Select all that apply.) 1. "What does your family do to keep members healthy?" 2. "How does your family usually make decisions?" 3. "What health services are available in your neighborhood?" 4. "Which rituals or celebrations are important for your family?" 5. "Is there a lot of crime in your neighborhood?" 6. "How many parks are there in your community?"
1, 2, 4
A family is facing job loss of the father, who is the major wage earner, and relocation to a new city where there is a new job. The children will have to switch schools, and his wife will have to resign from the job she enjoys. Which of the following contribute to this family's hardiness? (Select all that apply.) 1. Family meetings 2. Established family roles 3. New neighborhood 4. Willingness to change in time of stress 5. Passive orientation to life
1, 2, 4
A nurse is conferring with another nurse about the care of a patient with a stage II pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (Select all that apply.) 1. Allows nurses to act more quickly and appropriately 2. Sets a level of clinical excellence for practice 3. Eliminates need to create an individualized care plan for the patient 4. Incorporates evidence-based interventions for stage II pressure injury 5. Provides for access to patient care information within the electronic health record
1, 2, 4
A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.) 1. The nurse reviews the options for pain relief for the patient. 2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed. 3. The nurse reviews the policy and procedure for the cold application. 4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy. 5. The nurse delegates vital sign assessment of the patient returning from surgery to the assistive personnel.
1, 2, 4
A nurse asks how a patient's condition from a serious infection changed since yesterday while receiving a hand-off report. The 280nurse leaving the shift reports the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins to provide care by measuring the patient's body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient's progress since the day before. The nurse asks a technician to measure intake and output during the shift. What critical thinking indicators reflect the nurse's ability to perform evaluation? (Select all that apply.) 1. Checking the summary notes 2. Asking the leaving RN about the patient's condition. 3. Assigning the technician to measure intake and output 4. Comparing current outcomes with those set for the patient's goals 5. Reflecting on patient's progress
1, 2, 4, 5
A nurse completes the following steps during her shift of care. Which are the steps of nursing assessment? (Select all that apply.) 1. The review of patient data in the medical record 2. Confirming a patient's self-report of abdominal pain by inspecting the abdomen 3. Reporting results of an ongoing assessment to a nurse working the next scheduled shift 4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration 5. Conducting an interview of a family caregiver
1, 2, 4, 5
Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain
1, 2, 6, 8
Setting priorities for a patient's nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care? (Select all that apply.) 1. Priority setting establishes a preferential order for nursing interventions. 2. In most cases wellness problems take priority over problem-focused problems. 3. Recognition of symptom patterns helps in understanding when to plan interventions. 4. Longer-term chronic needs require priority over short-term problems. 5. Priority setting involves creating a list of care tasks.
1, 3
When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure injuries 5. To immobilize area
1, 3
A nurse in a community health clinic has been caring for a young female teenager with diabetes for several months. The nurse's goal of care for this patient is to achieve self-management of insulin medication. Identify appropriate evaluative measures for self-management for this patient. (Select all that apply.) 1. Quality of life 2. Patient satisfaction 3. Clinic follow-up visits 4. Adherence to self-administration of insulin 5. Description of side effects of medications
1, 3, 4
A nurse is caring for a 66-year-old patient who lives alone and is receiving chemotherapy and radiation for a new cancer diagnosis. He is unable to care for himself because of severe pain and fatigue. He moves into his 68-year-old brother's home so his brother can help care for him. Which assessment findings indicate that this family caregiving situation will be successful? (Select all that apply.) 1. Both the patient and his brother attend church together regularly. 2. The brothers are living together and enjoy eating the same foods. 3. Other siblings live in the same city and are willing to help. 4. The patient and his brother have a close network of friends. 5. The patient has obsessive-compulsive disorder and has difficulty throwing away possessions.
1, 3, 4
What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Maintain regular bowel elimination. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.
1, 3, 4
Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.) 1. Recognize normal changes associated with aging. 2. Avoid direct eye contact. 3. Lean forward and smile as you pose questions. 4. Allow for pauses as patient tells his story. 5. Use the list of questions from the clinic assessment form to complete all data.
1, 3, 4
Which of the following statements correctly describes the evaluation process? (Select all that apply.) 1. Evaluation involves reflection on the approach to care. 2. Evaluation involves determination of the completion of a nursing intervention. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is performed only when a patient's condition changes.
1, 3, 4
Which of the following factors should be considered when choosing an intervention for a patient's plan of care? (Select all that apply.) 1. The specific patient outcome against which to judge effectiveness of interventions 2. The timing of care activities routinely conducted on the care unit 3. The scientific evidence available in support of an intervention 4. The amount of time required for implementation in consideration of patient's condition 5. The patient's values and beliefs regarding the intervention
1, 3, 4, 5
Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine
1, 3, 5
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.
1, 4
Which of the following best describe a collaborative health problem? (Select all that apply.) 1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status 2. The language medical practitioners use to communicate a patient's health problem and associated treatments and response 3. A diagnostic label that classifies a patient's response to illness so that all nurses can be familiar with a specific patient's health care needs 4. A language used by health care providers to communicate and consider each other's unique perspective, so they can better manage the multiple factors that influence the health of individuals 5. A diagnosis that provides clear direction as to the type of nursing interventions nurses are licensed to provide independently
1, 4
A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.
1, 4, 5
Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment
1, 4, 5
Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.
1, 5, 6
a nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68 / minute and of the simultaneous apical pulse rate is 84 / minute. What is the client's pulse deficit?
16/min
A nurse on a hospital unit is preparing to hand off care of a patient being discharged to a home health nurse. Match the activities on the left with the hand-off report categories on the right. A. Strategy for Effective Hand-off B. Strategy for Ineffective Hand-off 1. Use a standard checklist for the report. 2. Encourage questions and clarification. 3. Offer specific information on how to reduce patient's risks. 4. Give report at time when shift has ended and other nurses are requesting information. 5. Explain how patient's discharge was delayed by insufficient numbers of staff. 6. Organize time by preparing in advance what to report.
1a, 2a, 3a, 4b, 5b, 6a
Match the assessment activity on the left with the type of assessment on the right. A. Problem focused B. Comprehensive 1. Assessment conducted at beginning of a nurse's shift 2. Review of a patient's chief complaint 3. Completion of admitting history at time of patient admission to a hospital 4. Completion of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home
1a, 2a, 3b, 4b
a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). b. Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. c. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. d. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
1b, 2a, 3d, 4c
Match the category of direct care on the left with the specific direct care activity on the right. 1. Counseling ___ 2. Lifesaving measure ____ 3. Physical care technique ___ 4. Activity of daily living ____ a. Assisting patient with oral care b. Discussing a patient's options in choosing palliative care c. Protecting a violent patient from injury d. Using safe patient handling during positioning of a patient
1b, 2c, 3d, 4a
An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. 1. _____ Patient will ambulate independently in 3 days. 2. _____ Patient will be injury free for 1 month. 3. _____ Patient will achieve 5-pound weight gain in 1 month. 4. _____ Patient will achieve pain relief by discharge. a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 calories daily. c. Patient walks 20 feet using a walker in 24 hours. d. Patient identifies barriers to remove in the home within 1 week.
1c, 2d, 3b, 4a
Match the elements for correct identification of outcome statements with the SMART acronym terms below. 1. Specific 2. Measurable 3. Attainable 4. Realistic 5. Timed a. Mutually set an outcome that a patient agrees to meet. b. Set an outcome that a patient can meet based upon his or her physiological, emotional, economic, and sociocultural resources. c. Be sure an outcome addresses only one patient behavior or response. d. Include when an outcome is to be met. e. Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient's status.
1c, 2e, 3a, 4b, 5d
From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O). 1. _____ Will achieve pain relief 2. _____ Ambulates 10 feet down hallway 3. _____ Will remain free of infection 4. _____ Will be afebrile 5. _____ Reports pain severity reduced from 6 to a 4 on scale of 0 to 10 6. _____ Will gain improved mobility
1g, 2o, 3g, 4g, 5o, 6g
A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. The nurse focuses on symptom management for the grandmother and on helping the family with developing coping skills. This approach is an example of which of the following? 1. Family as context 2. Family as patient 3. Family as a system 4. Family as structure
2
A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Reflection. 2. Clinical inference. 3. Cue. 4. Validation.
2
A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? 1. Incorrect clustering of data 2. Wrong diagnosis 3. Condition is a collaborative problem 4. Premature ending assessment
2
A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient's airways. When the nurse asks how the patient feels, he responds by saying, "I feel as if I can breathe better." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following evaluative measures may not reflect change in a patient's condition? 1. Counting respirations per minute 2. Asking the patient to describe how his breathing feels 3. Observing breathing pattern 4. Auscultating lung sounds
2
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication. 2. Establish a toileting schedule. 3. Recommend that she be evaluated for an indwelling catheter. 4. Start a bladder-retraining program.
2
During a visit to a family clinic, a nurse teaches a mother about immunizations, the use of car seats, and home safety for an infant and toddler. Which type of nursing interventions are these? 1. Restorative 2. Health promotion 3. Acute care 4. Growth and development
2
The nurse asks a patient the following series of questions: "Describe for me how much you exercise each day." "How do you tolerate the exercise?" "Is the amount of exercise you get each day the same, less, or more than what you did a year ago?" This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data interpretation 4. Termination
2
There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter farther.
2
What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear.
2
Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3 Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water
2
A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) 1. Increase the rate of the CBI. 2. Assess the patency of the drainage system. 3. Measure urine output. 4. Assess vital signs. 5. Administer ordered pain medication.
2, 3
Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. 4. Pull the catheter quickly. 5. Clamp the catheter before removal.
2, 3
The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) 1. The application of the skin barrier is a dependent care measure. 2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activity of daily living. 5. Inspecting the skin is a direct care activity.
2, 3,
A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in? (Select all that apply.) 1. Data collection 2. Data clustering 3. Data interpretation 4. Making a diagnostic statement 5. Goal setting
2, 3, 4
A mother and her two children are homeless and enter a free health care clinic. Which statements most likely describe the effects of homelessness on this family? (Select all that apply.) 1. The children have stability in their education. 2. The family members may have symptoms of malnutrition, such as anemia. 3. The family is at a low risk for experiencing violence. 4. The children are at higher risk for developing ear infections. 5. All family members may have mental health issues.
2, 4, 5
A nurse admits a 32-year-old patient for treatment of acute asthma. The patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse makes the patient comfortable and starts an ordered intravenous infusion to administer medication that will relax the patient's airways. The patient tells the nurse after the first medication infusion, "I feel as if I can breathe better." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following is an evaluative measure? (Select all that apply.) 1. Asking patient to breathe deeply during auscultation 2. Counting respirations per minute 3. Asking the patient to describe how his breathing feels 4. Starting the intravenous infusion 5. Auscultating lung sounds
2, 3, 5
A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one registered nurse (RN) as a result of a call-in. A patient care technician from another area is coming to the nursing unit to assist. Because the unit requires hourly rounds on all patients, the nurse begins to make rounds on a patient who recently asked for a pain medication. The nurse is interrupted by another registered nurse who asks about another patient. Which factors in this nurse's unit environment will affect the ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. Type of hospital unit 5. Competency of patient care technician
2, 3, 5
A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.) 1. The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure. 269 2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient. 3. The nurse directs the patient care technician to set up meal trays for patients. 4. The nurse directs the patient care technician to gather a history from the newly admitted patient about his medications. 5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.
2, 3, 5
A patient diagnosed with colon cancer has been receiving chemotherapy for 6 weeks. The patient visits the outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty accessing the patient's intravenous (IV) port used to administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This also occurred 2 weeks earlier. What steps should the nurse follow to make a consultation with a member of the IV infusion team? (Select all that apply.) 1. Ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second patient. 2. Specifically identify the problem of port obstruction, and attempt to flush the port to resolve the problem. 3. Explain to the IV nurse the frequency in which this port has obstructed in the past. 4. Tell the IV nurse the problem is probably related to the physician who inserted the port. 5. Describe to the IV nurse the type and condition of the port currently in use.
2, 3, 5
A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. 1. Consider the context of patient's health problem and select a related factor. 2. Review assessment data, noting objective and subjective clinical information. 3. Cluster clinical data elements that form a pattern. 4. Identify appropriate assessment findings for diagnosis. 5. Identify a nursing diagnosis.
2, 3, 5, 1, 4
A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes, usually twice or more." The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.) 1. Age 42 2. Dysuria 3. Difficulty performing perineal hygiene 4. Nocturia 5. Episode of diarrhea
2, 4
A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) 1. Reviewing the family caregiver's availability during medication administration times 2. Determining the value the patient places on taking medications 3. Reviewing the number of medications and time each is to be taken 4. Determining all consequences associated with the patient missing specific medicines 5. Reviewing the therapeutic actions of the medications
2, 4
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Offer frequent skin care because of Impaired Skin Integrity 2. Risk of Infection 238 3. Chronic Pain related to osteoarthritis 4. Activity Intolerance related to physical deconditioning 5. Lack of Knowledge related to laser surgery
2, 4
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure
2, 4
A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the past month." 2. "My name is Terry. I'll be the nurse taking care of you today." 3. "I have no further questions. Is there anything else you wish to ask me?" 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the past month, and your appetite has been poor—correct?"
2, 4, 1, 5, 3
Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
2, 5
A family includes a mother, a stepfather, two teenage biological daughters of the mother, and a biological daughter of the father. The father's daughter just moved home following the loss of her job in another city. The family is converting a study into a bedroom and is in the process of distributing household chores. Nursing assessment reveals all members of the family think that their family can adjust to lifestyle changes. This is an example of family: 1. Diversity. 2. Durability. 3. Resiliency. 4. Configuration.
3
A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which of the following is appropriate for evaluating a patient's expectations of care? 1. On a scale of 0 to 10 rate your level of nausea. 2. The nurse weighs the patient. 3. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" 4. The nurse states, "Tell me four different foods included in your diet."
3
A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.
3
A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? 1. Patient in pain 2. Patient newly admitted 3. Patient who returned from surgery 4. Patient requesting assistance with meal tray
3
A nursing student is providing a hand-off report to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated walking to end of hall each time and back with no shortness of breath. Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changed the dressing over his intravenous (IV) site and started a new bag of D5½NS. Which intervention is a dependent intervention? 1. Providing hand-off report at change of shift 2. Enhancing the patient's sleep hygiene 3. Administering IV fluids 4. Taking vital signs
3
A young male patient enters the emergency department with fever and signs of a possible sexually transmitted infection. The nurse enters the patient's cubicle and begins to enter a history on the computer screen. Before beginning the nurse introduces himself and tells the patient all information will be held confidentially. The nurse starts data collection by establishing eye contact with the patient and then looks at the computer prompts to select a series of questions. As the nurse fills out questions on the computer, the patient asks a question about his treatment. The nurse states, "Let me get through these questions first." Which action interferes with the nurse's ability to use connection as a communication skill. 1. Introducing self to patient 2. Using the computer as a prompt for questions 3. Making the nurse's questions a priority 4. Assuring the patient all information is confidential
3
What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bedsheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert ¼ inch more.
3
Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.
3
Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? 1. Knowing the source of the guideline 2. Reviewing the evidence used to develop the guideline 3. Individualizing how to apply the clinical guideline for a patient 4. Explaining to a patient the purpose of the guideline
3
A nursing student is providing a hand-off report to a registered nurse (RN) who is assuming her patient's care at the end of the clinical day. The student states, "The patient had a good day. His intravenous (IV) fluid is infusing at 124 mL/hr with D5½NS infusing in left forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated walking to the visitors lounge and back with no shortness of breath, respirations 14, heart rate 88 after exercise. He uses his walker without difficulty, gait normal. The patient ate ¾ of his dinner with no gastrointestinal complaints. For the goal of improving the patient's activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) 1. IV site not tender 2. Uses walker to walk 3. Walked to visitors lounge 4. No shortness of breath 5. Tolerated dinner meal
3, 4
A married couple has three children. The youngest child just graduated from college and is moving to a different city to take a job. The other two children left the home several years ago. Both of their parents are older and are beginning to need help to maintain their home. What assessment questions will help the nurse determine the family's functioning? (Select all that apply). 1. Which transitions or changes in your family are you currently experiencing? 2. Are your children having any problems that are affecting your family right now? 3. Describe a recent family conflict and how your family resolved it. 4. What coping strategies do you typically use as a family? 5. Who is involved in helping care for your parents?
3, 4, 5
A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient's lungs and hears crackles in the left lower lobe. The patient's respiratory rate is 20 per minute compared with an average of 16 per minute during previous clinic visits. The patient tells the nurse, "It is hard for me to get a breath." Which of the following data sets are examples of subjective data? (Select all that apply.) 1. Heart rate of 20 per minute and chest congestion 2. Lung sounds revealing crackles and use of intercostal muscles to breathe 3. Patient statement, "It's hard for me to get a breath" 4. Slumped posture and previous respiratory rate of 16 per minute 5. Patient report of sore throat and hoarseness
3, 5
Place the following steps of the assessment process in the correct order. 1. Compare data with another source to determine data accuracy. 2. As a pattern forms, probe and frame further questions. 3. Interview a patient, observe behavior, and gather physical assessment findings. 4. Cluster cues that relate together, make inferences, and identify emerging patterns. 5. Differentiate important data from the total data you collect.
3, 5, 4, 2, 1
A 7-year-old child was recently diagnosed with asthma. A nurse is providing education to the child and her parents about the treatment and management of asthma and changes they need to make in their home environment to promote her health. Which statement made by the parents requires follow-up by the nurse? 1. "We have made an appointment to talk with the school nurse about the change in our child's health." 2. "We forgot to give our daughter her medications before bedtime, so we made a list of her medications to help us remember." 3. "We have worked out a schedule to check on her before and after school." 4. "We have not been spending time with our parents because we are so busy taking care of our daughter."
4
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the past 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal formed stool within 48 hours. 3. Patient's ability to turn self in bed improves. 4. Erythema of skin will be mild to none within 48 hours.
4
A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient's heart rate is 92 compared with 76 preoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postop dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on the patient's situation? 1. The patient is recovering normally. 2. The symptoms reflecting restlessness 3. The patient's blood pressure trend 4. The delay in administration of the analgesic
4
A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster.
4
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?
4
The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance
4
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode
4
Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface
4
What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.
4, 3, 2, 5, 1
In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?226 1. Current medications 2. Patient expectations of planned surgery 3. Review of patient's family support system 4. History of allergies 5. Patient's explanation for what might be the cause of symptoms that require surgery
5
Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.
5, 7, 2, 4, 1, 6, 3, 8, 9
Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.
5, 8, 7, 2, 6, 3, 4, 1
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the clients MAR and noted the last dose of pain medication was 6 hours ago. The prescription reads every 4-Hour PRN for pain. The nurse administered the medication and checked with the client 40 minutes later, when the client reported Improvement. The newly Licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation
a
A nurse is caring for a client who is 24 hour postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, is expressing a desire for "real food". the nurse tells the client "I will call the surgeon and ask for a change in diet". The surgeon hears the nurses report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? a. Basic B. commitment C. complex D. integrity
a
A patient comes from a close-knit family. The patient's family functions as context. You will need to evaluate: A. attainment of patient needs. B. family attainment of developmental tasks. C. individual family members caring about one another. D. family satisfaction with its new level of functioning.
a
By the second postoperative day, a client has not achieved satisfactory pain relief. based on this evaluation, which of the following actions should the nurse take, according to the nursing process? a. reassess the client to determine the reasons for inadequate pain relief b. wait to see whether the pain lessens during the next 24 hr c. change the plan of care to provide different pain relief interventions d. teach the client about the plan of care for managing the pain
a
Collaborative interventions are therapies that involve which of the following? a. More than one health care professional b. Nurse and client c. Client and physician d. Nurse and physician
a
The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges: A. are approximated. B. migrate across the incision. C. appear slightly pink. D. slightly overlap each other.
a
a client who has an indwelling catheter reports of need to urinate. Which of the following actions should the nurse take? a. Check to see whether the catheter is Patent B. reassure the client that it is not possible for them to urinate C. free catheterize the bladder with a larger gauge catheter D. I want to hear in specimen for analysis
a
a nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? a. Knowledge B. experience C. intuition D. competence
a
a nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take? a. Describe the first voiding B. keeping urine in a single container at room temperature C. dispose of the last voiding D. ask the client to urinate into the toilet stop Midstream and finish urinating into the specimen container
a
a nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify appropriate for the planning step of the nursing process? a. I will determine the most important client problems that we should have should address b. I will review the past medical history on the client's record to get more information c. I will carry out the new prescriptions from the provider d. I will ask the client if their nausea has resolved
a
a nurse is instructing an assistive Personnel about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? a. Do not measure the clients temperature rectally B. count the client's radial pulse for 30 seconds and multiply by 2 C. do not let the client know you are counting the respiration D. what the client rest for five minutes before you measure their blood pressure
a
a nurse is performing an admission assessment for an older adult client. After Gathering the assessment data and Performing the review of systems, which of the following actions is a priority for the nurse? a. Orient the client to the room B. conductor client care conference C. review medical prescriptions D. develop a plan of care
a
for a student to avoid a data collection error, the student should: a. assess the patient and, if unsure of the finding, ask a faculty member to assess the patient b. review his or her own comfort level and competency with assessment skills c. ask another student to perform the assessment d. consider whether the diagnosis should be actual, potential, or risk
a
nurse-initiated interventions are a. determined by state Nurse Practice Acts b. supervised by the entire health care team c. made in concert with the plan of care limited by the physician d. developed after interventions for the recent medical diagnoses are evaluated.
a
a patient is suffering from shortness of breath. the correct goal statement would be written as: a. the patient will be comfortable by the morning b. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. c. the patient will not complain of breathing problems within the next 8 hours. d. the patient will have a respiratory rate of 14 to 18 breaths per minute
b
you have finished with several nursing interventions. to evaluate interventions, you need to examine the: a. appropriateness of the interventions and the correct application of the implementation process b. nursing diagnoses to ensure that they are nit medical diagnoses c. care planning process for errors in other health care team members' judgements d. interventions of each nurse to enable the nurse manager to correctly evaluate performance
a
The evaluation phase of the should include which of the following? (Select all that apply.) a. Reassessment b. Compare baseline and current condition c. Implement interventions d. Occur at end of shift e. Apply only to nursing care
a, b
a newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take?( Select all that apply) a. find a mentor B. use a journal to write about the outcomes of clinical judgement C. review articles about evidence based practice D. limit consultations with other professionals involved in a client's care E. make quick decisions when unsure about a client's name
a, b, c
a nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the General survey?( Select all that apply) a. Pause B. skin lesions C. speech D. allergies E. immunization status
a, b, c
a nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. the surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. which of the following findings should the nurse expect? (select all that apply) a. increase in incisional pain b. fever and chills c. reddened wound edges d. increase in serosanguineous drainage e. decrease in thirst
a, b, c
a nurse is instructing a group of assistive Personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include?( Select all that apply) a. place the client in semi Fowler's position B. have the client rest in arm across the abdomen C. observe one full respiratory cycle before counting the right D. count the rate for 30 seconds if it is a regular E. report any sighs the client demonstrates
a, b, c
a nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take?(select all that apply) a. warm the enema solution prior to installation B. position the client on their left side with the right leg flexed forward C. lubricate the rectal tube or nozzle D. well we insert the rec about 5 cm( 2 in) E. hang the enema container 61 cm( 24 in) above the clients anus
a, b, c
A nursing assessment will include information from which sources? (Select all that apply.) a. Physical assessment b. Family members c. Other clients d. Health history e. Closed-ended questions
a, b, d
a nurse is admitting a client who has acute cholecystitis for medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (select all that apply) a. Explain the rules of the other care delivery staff B. begin discharge planning C. inform the client that advance directives are required for hospital admission D. document the clients which is about organ donation E. introduce a client to The Roommate
a, b, d, e
while a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold their breath briefly in Bear Down B. Clamp the enema tubing C. remind the client. Cramping is common this time D. raise the level of the enema fluid container
b
a nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (select all that apply) a. Ensure that the client has possession of their valuables B. confirm that the rehabilitation center has a room available at the time of transfer C. assess how the client tolerance to transfer D. give a verbal transfer report via telephone D. complete a transfer form for the receiving facility
a, b, d, e
a nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 degrees Celsius( 101 degrees Fahrenheit), pulse rate 114 / minute, and respiratory rate 22/ minute . the client is restless with warm skin. Which of the following interventions should the nurse take?( Select all that apply) a. obtain culture specimens before initiating antimicrobial B. restrict the client's oral fluid intake C. encourage the client to rest and limit activity D. allow the client to shiver to dispel excess Heat E. assist the client with oral hygiene frequently
a, c, e
a client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. the nurse checks the surgical wound and finds it separated with viscera protruding. which of the following actions should the nurse take? (select all that apply) a. cover the area with saline-soaked dressings b. apply an abdominal binder snugly around the abdomen c. use sterile gauze to apply gentle pressure to the exposed tissues d. position the patient supine with the hips and knees bent e. offer the client a warm beverage (herbal tea)
a, d
a nurse is caring for a client who is at risk for developing pressure injury. which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (select all that apply) a. keep the head of the bed elevated at 30 degrees b. massage the client's bony prominences frequently c. apply cornstarch liberally to the skin after bathing d. have the client sit on a gel cushion when in a chair e. reposition the client at least every 3 hr while in bed
a, d
a charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (select all that apply) a. respiratory rate is 22 / min with even, unlabored respirations b. the clients partner States, " they said they hurt after walking about 10 minutes" c. the client's pain rating is 3 on a scale of 0 to 10 d. the client's skin is pink, warm, and dry e. the assistive Personnel reports that the client walked with a limp
a, d, e
a nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. which of the following findings should the nurse expect? (select all that apply) a. capillary refill less than 3 seconds b. 1+ pitting edema in both feet c. pale nail beds in both hands d. thick skin on the soles of feet e. numerous macules on the face darker than the surrounding skin color
a, d, e
a nurse is reviewing factors that increase the risk of urinary tract infections with a client who has recurrent UTI. which of the following factors should the nurse include?(select all that apply) a. Frequent sexual intercourse B. lowering of testosterone levels C. wiping from front to back to clean the perineum D. location of the urethra closer to the anus E. frequent catheterization
a, d, e
a nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply) a. stage 3 pressure injury b. sutured surgical incision c. casted bone fracture d. laceration sealed with adhesive e. open burn area
a, e
your patient has met the goals set for improvement of ambulatory status. you would now: a. modify the care plan b. discontinue the care plan c. create a new nursing diagnosis that states goals have been met d. reassess the patient's response to care and evaluate the implementation step of the nursing process
b
A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with: A. abnormal defecation. B. constipation. C. fecal impaction. D. fecal incontinence.
b
A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of: a. evaluation b. data collection c. problem identification d. testing a hypothesis
b
To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: A. the presence of food stimulates peristalsis. B. mass colonic peristalsis occurs at this time. C. irregularity helps to develop a habitual pattern. D. neglecting the urge to defecate can cause diarrhea.
b
Which of the following is an example of objective data? a. Pain b. Weight c. Dizziness d. Nausea
b
a nurse is collecting data for a client's comprehensive physical examination. After inspecting the clients abdomen, which of the following skills of the physical examination process should the nurse perform next? a. Olfaction B. auscultation C. palpation D. percussion
b
a nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140 / 94 millimeters of mercury and the client denies any history of hypertension. Which of the following actions should the nurse take first? a. Request a prescription for an antihypertensive medication B. ask a client if they are having Pain C. request a prescription for an anti-anxiety medication D. return in 30 minutes to re-check the client's blood pressure
b
a nurse is performing an integumentary assessment for a group of clients. which of the following findings should the nurse recognize as requiring immediate intervention? a. pallor b. cyanosis c. jaundice d. erythema
b
a nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A. Macaroni and cheese B. one medium apple with skin C. one cup of plain yogurt D. roast chicken and white rice
b
a nurse manager is assigning care of a client who is being admitted from the pacu following thoracic surgery. The nurse manager should assign the client to which of the following staff members? a. Charge nurse B. registered nurse C. practical nurse D. assistive personnel
b
a nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes that did the nurse demonstrate? a. Furnace B. responsibility C. risk take D. creativity
b
a nurse is performing skin assessments on a group of clients. which of the following lesions should the nurse identify as vesicles? (select all that apply) a. acne b. warts c. psoriasis d. herpes simplex e. varicella
d, e
a nurse is assessing an older adult client who has significant tenting of the skin over the forearm. which of the following factors should the nurse consider as a cause for this finding? (select all that apply) a. thin, parchment-like skin b. loss of adipose tissue c. dehydration d. diminished skin elasticity e. excessive wrinkling
b, c, d
a nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. their Hgb is 12 g/dl and BMI is 17.1. the incision is approximated and free of redness, with scant serous drainage on the dressing. the nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply) a. extremes in age b. chronic illness c. low hemoglobin d. malnutrition e. poor wound care
b, c, d
a nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP which of the following information should the nurse share with the AP?(select all that apply) a. The roommate ambulate independently B. the client ambulates wearing slippers over antiembolic stockings C. the client uses a front wheeled walker when ambulating D. the client had pain medication 30 minutes ago E. the client is allergic to codeine F. the client ate 50% of breakfast this morning
b, c, d
a nurse is preparing to initiate a bladder retraining program for a client who has incontinence. Which of the following actions should the nurse take? (select All that apply) a. restart the clients intake of fluids during the day B. Tumblr client record urination time C. gradually increase the urination intervals D. remind the client to hold urine until the next scheduled urination time E. provide a sterile container for urine
b, c, d
a nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the clients age?(Select all that apply) a. expect the session to be shorter than for a younger client B. plan to allow plenty of time for position changes C. make sure the client has any essential sensory aids in place D. tell the client to take their time answering questions E. invite the client to use the bathroom before beginning the examination
b, c, d, e
A nurse provides an introduction to a client at the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client?( select all that apply) a. Address the client with the appropriate title and their last name B. use a mix of open and closed-ended questions C. reduce environmental noise D. have the client complete a Printed history form E. perform the General survey before the examination
b, c, e
a nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. the nurse should test which of the following? (select all that apply) a. range of motion b. skin color c. edema d. skin lesions e. skin temperature
b, c, e
a nurse is preparing an in-service program about delegation. Which of the following are components of the Five Rights of Delegation?(select all that apply) a. Right place B. right supervision and evaluation C. right direction and communication D. right documentation E. right circumstances
b, c, e
a nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (select all that apply) a. Advance directive status B. follow up care C. instructions for diet and medications D. most recent Vital sign data E. contact information for the home healthcare agency
b, c, e
A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include?(select all that apply) a. women total daily fluid intake B. increase our avoid caffeine C. take calcium supplements D. avoid drinking alcohol E. use the Crede maneuver
b, d
a nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect?( Select all that apply) A. bradycardia B. hypotension C. elevated temperature D. poor skin turgor E. peripheral edema
b. c. d
What does the "I" in in the acronym ADPIE represent? a. Imply b. Intervention c. Implementation d. Interest
c
When completing the nursing data on a client, to complete the admission and develop a plan of care, the nurse will need to: A. test the family unit's ability to cope. B. evaluate communication patterns. C. identify family unit form and attitudes. D. gather health data from all family members.
c
You are caring for a patient. Visitors at the bedside include the patient's life partner, widowed father, brother, and niece. The nurse acknowledges that current trends in American families include: A. couples without children. B. more singles choosing to live alone. C. a very different look from 15 years ago. D. a mother, father, and more than one child.
c
a charge nurse is assigning plant care for four clients. Which of the following tasks should the nurse assigned to a PN? a. Creating a plan of care for a client who is recovering following a stroke B. assessing a pressure injury on a client who is on bedrest C. providing nasopharyngeal suctioning for a client who has pneumonia D. teaching a client who has as much as use a metered dose inhaler
c
a nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin type? a. Palmar surface B. fingertips C. dorsal surface D. base of the finger
c
a nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. which of the following tasks should the nurse assigned to an assistive personnel? a. Updating the plan of care for a client who is post-operative B. reinforcing teaching with a client who is learning to walk using a quad cane C. re applying a condom catheter for a client who has urinary incontinence D. applying a sterile dressing to a pressure injury
c
a patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. the patient asks the nurse where urine is formed in the kidney. the nurse's response is the : a. bladder b. kidney c. nephron d. ureter
c
consultation occurs most often during which phase of the nursing process? a. assessment b. diagnosis c. planning d. evaluation
c
when caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a: a. critical pathway b. nursing care plan c. concept map d. diagnostic label
c
a charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (select all that apply) a. writing a prescription for morphine sulfate as needed for pain b. inserting a nasogastric tube to relieve gastric distention c. showing a client how to use progressive muscle relaxation d. performing a daily bath after the evening meal e. repositioning a client every 2 hours to reduce pressure injury risk
c, d, e
The nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will need to incorporate nursing process and: a. decision making b. problem solving c. interview process d. intellectual standards
c. interview process
A health care provider may suspect that a patient is experiencing urinary retention when the patient has: A. large amounts of voided cloudy urine. B. pain in the suprapubic region. C. spasms and difficulty during urination. D. small amounts of urine voided two to three times per hour.
d
A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: A. it has no odor. B. a culture is negative. C. the edges reveal the presence of fluid. D. it shows purulent drainage coming from the incision site.
d
A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: A. an absorbent surface to collect wound drainage. B. decreased incidence of skin maceration. C. potection from the external environment. D. moisture needed for wound healing.
d
A young girl is having problems urinating postoperatively. You remember that children may have trouble voiding: A. in bathrooms other than their own. B. in a urinal. C. while lying in bed. D. in the presence of a person other than one of their parents.
d
The nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? A. Eating more protein is optimal prior to testing B. 1 stool specimen is sufficient for testing C. a red color change indicates a positive test D. specimen cannot be contaminated with urine
d
Which of the following is an example of subjective data? a. Wound appearance b. Heart Rate c. Temperature d. Anxiety
d
Which of the following nursing diagnosis statements is correctly formatted? a. Obesity related to overweight as evidenced by patient states feels "fat" b. Acute Pain related to chronic pain as evidenced by overuse of pain medications c. Risk for suicide related to history of suicide attempt as evidenced by suicidal ideations, recent suicide attempt d. Activity Intolerance related to immobility as evidenced by respirations of 16 and heart rate of 70
d
a nurse uses I had to tell her approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? a. Confidence B. perseverance C. integrity D. discipline
d
as part of the admission process, a nurse at a long-term care facility is gathering an Egyptian history for a client who has dementia. Which of the following components of the nutrition of valuation is the priority for the nurse to determine from the client's family? a. Body mass index b. usual times for meals and snack C. favorite food D. any difficulty swallowing
d
you are writing a care plan for a newly admitted patient. which one of these outcome statements is written correctly? a. the patient will eat 80% of all meals b. the nursing assistant will set the patient up for a bath every day c. the patient will have improved airway clearance by June 5 d. the patient will identify the need to increase intake of fiber by june 5
d
Concept mapping is one way to: a. connect concepts to a central subject b. relate ideas to patient health problems c. challenge a nurse's thinking about patient needs and problems d. graphically display ideas by organizing data e. all of the above
e
The implementation phase of the nursing process is when you: a. use nursing outcomes b. classification (NOC). c. record the care plan. d. evaluate the objectives. e. give the nursing care.
e
Fill in the Blank: A(n)__________________________ diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem.
risk diagnosis