Nursing 101 Exam 2: practice questions
The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?
"Only authorized persons are allowed to access client records."
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6l per minute
HIPAA allows incidental disclosures of client health information as long as it cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of client health information. What are examples of this type of client health information disclosure? Select all that apply.
A visitor hears a confidential conversation between two nurses in surroundings that are appropriate and with voices that are kept low. The nurse uses x-ray light boards that can be seen by passersby; however, client x-rays are not left unattended on them. The nurse calls out names in the waiting room, but does not disclose the reason for the client visit.
A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment?
Adds depth to existing information
Nurses formulate different types of goals for clients when planning client care. What is considered a psychomotor client goal?
By 18AUG2015, client will demonstrate improved motion in left arm.
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
Confusion
A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information?
Consult nursing and medical literature.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?
Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement
The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?
Decrease background noises, as much as possible, before speaking
The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which of the following questions should she ask?
Do you work around loud noises at work?"
A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?
Educational
The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client?
Eliminating disturbing odors with adequate ventilation
The nurse is teaching a client how to take medications upon discharge. The client is alert and oriented, but unable to articulate teaching back to the nurse. What is the appropriate nursing action?
Give written instructions to the client and caregivers.
A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?
If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.
37s A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?
Knowledge deficit: Medications related to new medical diagnosis
A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?
Nebulizer
The nurse is caring for a client with a NANDA-I diagnosis of Imbalanced nutrition: Less than body requirements, related to difficulty breathing. The nurse would implement which measures to maintain an adequate nutritional status for this client? Select all that apply
Provide frequent oral hygiene, especially before meals. Distribute six small meals over the course of the day.
The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?
Reassess the appropriateness of the method of instruction.
During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and she believes she is in a hotel. How should the nurse best respond to this client's disorientation?
Reorient the client to place and time.
A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?
Telemedicine and mobile technology
During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?
The nurse should determine the reason for the client's refusal.
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
arterial blood gas
A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:
atelectasis.
A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?
client himself
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
corticosteroids
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:
crackles
which of the following is a s/sx of late hypoxia?
cyanosis
which of the following would lead to an increase in o2 demand? a. fever b. sleep c. taking a narcotic d. postural drainage
fever
The nurse formulates a nursing diagnosis for a client of: Impaired Physical Mobility related to postoperative pain as evidenced by difficulty ambulating. What descriptor does the nurse identify in this nursing diagnosis?
impaired
During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:
inform the client of the maintenance of confidentiality.
A concise document that provides most of the client's nursing and medical information is a(n):
kardex
The nurse is caring for a client who will be wearing a simple mask for oxygen delivery. What planning regarding the mask will the nurse include in the plan of care?
may cause anxiety in client with claustrophobia
The nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?
pH less than 7.35; HCO3 low; PaCO2 low
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
poor tissue perfusion
A nurse is preparing to convert a client's IV to an intermittent infusion device. The IV is connected to extension tubing. Before disconnecting the IV tubing from the extension tubing, the nurse clamps the extension tubing for which reason?
prevent air from entering the line
The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation?
providing a backrub with morning and evening care
The nurse is caring for a client who has problems coordinating his breathing with the inhaler use. Therefore, the client is unable to receive the full dose. Which would help maximize drug absorption in this client?
spacer
Which example indicates the use of an internal sensory receptor?
spitting out of hot coffee
the primary purpose of an oral airway is?
to prevent obstruction of the trachea by displacement of the tongue into the oropharynx
A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: agrees with each of the client's statements. attempts to write down everything the client says. uses broad, open statements to communicate with the client. reassures the client of good outcomes.
uses broad, open statements to communicate with the client.
