nursing final study guide pre class worksheets-2023

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A nurse is presenting an educational session regarding psychosocial development to a group of middle-aged adults. According to Erikson's theory, what activity should the nurse select to best meet the needs of this stage? 1. Providing opportunities to mentor school-age children 2. Giving the group handouts regarding peer socialization 3. Helping the members of this group find appropriate civic responsibility 4. Assisting the group members to look at their life accomplishments

An older client who has had a stroke is ready for hospital discharge. How should the gerontological nurse case manager support this client's independence? 1. Allow the client to be actively involved in all decisions made. 2. Make arrangements based on what the nurse feels is in the best interest of the client. 3. Work closely with the social worker and physician to make the decisions necessary for the client. 4. Set up a meeting with the family members so decisions can be made.

At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation? 1. Shared by the nurse and client 2. A return demonstration by the client 3. When the nurse is satisfied that the client can complete the technique

The nurse is caring for a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority? 1. Client will be able to set up and administer a nebulizer treatment by the end of the day. 2. Client will have increased activity level by the end of the week. 3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days. 4. Client will have a positive attitude about the diagnosis by the end of the month

12) An older client needs to access the Internet to complete a post hospitalization survey and update health information but the client does not have a computer and would not know how to use one. What should the nurse do? (Select all that apply.) 1. Suggest the client learn how to use a computer through classes held at a local library. 2. Provide times for the client to attend basic computer use classes through the community learning center. 3. Document that the client is resistant to instruction. 4. Notify the physician that the client will not be adhering to medical instruction as planned. 5. Identify the client as being noncompliant with instruction.

1,2

The nurse instructs a client on self-care for a new ostomy. Which client behaviors demonstrate that instruction has been effective? (Select all that apply.) 1. Client provides skin care and changes ostomy device. 2. Client states what items are needed to perform ostomy care. 3. Client is unable to identify changes in skin around the stoma. 4. Client does not want to do the care. 5. Client asks the spouse to learn how to perform the care.

1,2

11) The nurse serves as an educator of other healthcare personnel. In what capacity will this nurse participate in education? (Select all that apply.) 1. Preceptor of new graduate nurses 2. Instructing a part of the critical care course 3. Clinical instruction of nursing students 4. One-to-one teaching of clients 5. Teaching grandparents how to care for children

1,2,3

13) The nurse is caring for an older client living in the community. Which nurse actions demonstrate an understanding of the prevalent health concerns specific to the older adult client? (Select all that apply.) 1. Discusses the need for proper lighting-especially at night-to minimize the risk of falls 2. Assesses amount and frequency of the client's alcohol consumption patterns 3. Assesses the client's orientation to time, place, and person as well as short-term memory 4. Discusses the client's views on long-term residential care if the need arises 5. Asks the client to name and provide the reason for each medication he is currently taking

1,2,3,5

A school nurse is planning a program for adolescents about positive lifestyle choices. Which should the nurse keep in mind when planning content for this age group? (Select all that apply.) 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 4. Based on sources available within the school system 5. Accurate

1,2,3,5

The nurse is creating a teaching plan for a client recovering from total hip replacement surgery. What should the nurse include in this client's plan? (Select all that apply.) 1. The content to be included 2. The outcome for the teaching 3. The approaches used to teach the content 4. The evaluation of the effectiveness of teaching 5. The amount of time needed to cover the content

1,2,3,5

The nurse working in a community health office that is often frequented by young adults is assessing clients for suicide. Which factors should the nurse identify as indicating a problem in this area? (Select all that apply.) 1. Decreased interest in work 2. Weight loss 3. Depression 4. Brain dysfunction, including tumors 5. Sleep disturbances

1,2,3,5

The nurse is working with young adults in the community. What should the nurse realize as being the psychosocial developmental tasks of this population? (Select all that apply.) 1. Selecting a mate 2. Rearing children 3. Achieving civic responsibility 4. Finding a congenial social group 5. Developing adult leisure-time activities

1,2,4

The nurse is completing a spiritual assessment with a middle-aged client. What should the nurse recognize as expected characteristics of moral development in this client? (Select all that apply.) 1. Uses religion for comfort 2. Seeks religious explanations for death 3. Compares characteristics of various religions 4. Questions the purpose of religion in one's life 5. Relies upon spiritual beliefs to help with illness

1,2,5

The nurse is planning care for an older adult client. On what should the nurse focus if following the Functional Consequences Theory on aging? (Select all that apply.) 1. Promote safety. 2. Promote mental health. 3. Improve quality of life. 4. Promote spiritual health. 5. Promote growth and development.

1,3

1) The nurse explains the use, how it works, and the rationale for an incentive spirometer that a client needs to use after surgery. When mastering the use of this device, the client will demonstrate learning in which of Bloom's domains? 1. Cognitive 2. Psychomotor 3. Affective 4. Imitation

5) A client prescribed new medications and a low-fat diet for a heart problem is concerned about understanding all of the new information. Which nursing diagnosis should be used to guide this client's care? 1. Health-Seeking Behavior 2. Deficient Knowledge 3. Noncompliance 4. Risk for Myocardial Infarction

5) The nurse is preparing a teaching plan for a client. Which information should the nurse omit from the plan? 1. Content outline 2. Name of the nurse 3. Teaching methods 4. Learning outcomes

A client has had Alzheimer's dementia for a period of time and continues to live at home with the spouse. What would be one of the gerontological nurse's responsibilities? 1. Make sure the client is being prescribed appropriate medication. 2. Provide support for the spouse. 3. Assess the client early to ensure proper care. 4. Find a suitable long-term care facility for the client.

An adolescent reports feels pressure to participate in activities such as drinking parties and sexual explorations. What should the nurse do? 1. Tell the adolescent to stay away from "friends like that." 2. Be open to the concerns and provide accurate information about any questions. 3. Encourage the adolescent to accept psychosocial counseling. 4. Give the adolescent pamphlets on sexually transmitted diseases.

An occupational health nurse is providing a hypertension screening at a local manufacturing plant. Among the employees, the nurse should focus on which population? 1. Males and females equally 2. African American males 3. Asian American females 4. Caucasian females

An older client being discharged has questions about medications and care at home. Which should the gerontological nurse do? 1. Inform the physician that the client needs to go to a nursing home 2. Assess the client's independence and ability to function in his own home before discharge 3. Tell the client not to worry about going home 4. Invite the client's family to come to the hospital so the nurse can explain the client's care to them

During an educational session regarding physical changes of the middle-aged adult, a participant asks about typical weight changes. How should the nurse respond? 1. "Weight loss is no different during this time than at any other time of your life." 2. "Metabolism slows during middle age, which may result in weight gain." 3. "As long as you exercise appropriately, weight loss will be ensured." 4. "Weight loss is always a good idea, regardless of your age."

The nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, which action is the nurse's highest priority? 1. Provide written instructions before discharge. 2. Address any healing beliefs the family has. 3. Make sure the child comes back for the follow-up appointment. 4. Make sure the parents can set up the treatments for their child.

The nurse who works in a long-term care facility has noticed that one of the residents has been showing signs of impaired cognitive and self-care abilities over the last 2 weeks. Which should the nurse do? 1. Remember that memory loss is a normal, age-related change 2. Investigate for possible physiological problems 3. Instruct the staff to be extra attentive, as this person needs more assistance 4. Inform the resident's family that the resident probably has some form of dementia

A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this client's documentation? (Select all that apply.) 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client

2,3,4

9) The nurse is assessing a client's learning needs. On which elements should the nurse focus? (Select all that apply.) 1. Nurse's own knowledge 2. Client's age 3. Client's understanding of health problem 4. Sensory acuity 5. Learning style

2,3,4,5

A client is prescribed a 1,600-calorie diet. Of this diet, 30% of the intake should be protein, 20% fat, and 50% carbohydrates. How many grams of carbohydrates should the client ingest every day? Calculate to the nearest whole number.

200 grams

4) An older client comes to the clinic reporting gastrointestinal problems, including frequent constipation and indigestion, but denies any recent weight loss. What should these symptoms indicate to the nurse? 1. Could be caused by cancer 2. The need for an upper and lower GI x-ray series 3. Normal changes in muscle tone and activity 4. A gastric ulcer or colitis

6) When consulting Erikson's developmental theory, the nurse determines that which older adult will have the least difficulty being successful with the task of this stage? 1. A client who felt success through her children's accomplishments 2. A client who held his job and work status as the defining feature of his life 3. A client who maintained a balance between work and home 4. A client who planned to really enjoy life once she retired

A client comes to the clinic with a history of pain in his testicle. During the interview assessment, what information should be of concern to the nurse? 1. The client works as an auto-detailer. 2. He smokes half a pack of cigarettes per week. 3. He has not had a yearly exam for 5 years. 4. He does not perform testicular self-exams.

A client has been diagnosed with dementia. The family wants to know how to plan for the future. What is the best response by the nurse? 1. "Your family member's symptoms will get worse, but there are medications to stop the progress." 2. "You should plan right now on which long-term care facility you will want to utilize when the time comes." 3. "Dementia is a progressive deterioration. It's important for you to clearly understand what to look for in symptoms." 4. "Dementia can be treated once the cause is known."

A client needs discharge teaching regarding the use of a walker before going home however the client's room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, which is the best thing the nurse can do? 1. Wait until just prior to discharge, then do the teaching in the hospital lobby. 2. Close the door to the client's room and make sure there is no clutter on the floor before the teaching session begins. 3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the client's room. 4. Make sure a physical therapist is available to do the teaching and can see the client before discharge.

A gerontological nurse is helping a potential home health client acquire the supplies that will be needed once the client is discharged from acute care. When considering these supplies, what should the nurse recall? 1. Medicare will cover supplies, but only with a physician's written order. 2. Between insurance supplements and Medicare, the older client shouldn't have any difficulty with coverage. 3. Most clients in this age group live on a fixed income, and supplies used should be as economical as possible. 4. Clients have to be responsible for their own supplies.

The nurse is providing assistance at a community health fair for middle-aged clients. Which information should the nurse use when working with this group of clients? 1. The middle-aged person has decreased intellectual and cognitive abilities as a result of the normal aging process. 2. Adults make the transition into this stage easily and without problems. 3. Physical capabilities and functions decrease with age, but mental and social capacities tend to increase in the latter part of life. 4. Cognitive and intellectual abilities are somewhat decreased due to slower reaction time, loss of memory, and changes in perception and problem solving.

A client reports that an adult child has moved back home, which is causing issues in the family. Which factor should the nurse identify that is least likely contributing to this trend? 1. Maladaptive behavior 2. High unemployment rate 3. High housing costs 4. High incidence of chronic disease

A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching? 1. "It's going to take time for me to understand this whole thing." 2. "Let's make sure my spouse is around before you start explaining." 3. "I wish my doctor would have explained this more in depth." 4. "I'm feeling nauseous but go ahead and start anyway."

An older male client is upset because of a lack interest in sexual intercourse. What should the nurse explain about decreased sexual interest in older clients? 1. It does decrease and gradually disappears. 2. It should not be taken as seriously as it would be if the client were a younger person. 3. It is caused by decreased hormone activity and there is little that can be done about it. 4. It decreases but does not disappear.

In the review of an older client's chart, the nurse reads that the client has sarcopenia. What should the nurse expect the client to report? 1. Weight loss and nausea 2. Hair loss and thin skin 3. Bleeding and bruising tendencies 4. Lack of strength and tiring easily

The nurse is preparing information for a community health education seminar. Which statement should the nurse include regarding disease for the middle-aged adult? 1. Cancer is the leading cause of death in the age group from 25 to 64 years. 2. Coronary heart disease is the leading cause of death. 3. Leading causes of death include suicide and motor-vehicle crashes. 4. Injuries and chronic disease are the leading causes of death in this age group.

The nurse is providing education regarding early detection of breast cancer to a group of women between the ages of 30 and 40. According to recommendations from the American Cancer Society, which should the nurse instruct the clients to do? 1. Monthly breast self-exams - 2. Yearly mammogram 3. See a physician if there is a strong family history of breast cancer 4. Have an annual breast exam performed by a healthcare provider.

The nurse is working with a group of older clients through a community senior citizens center. In which way should the nurse support these clients' health literacy? 1. Provide information written at a third-grade level. 2. Use a variety of approaches when teaching 3. Provide information with pictures. 4. Ensure ample time for teaching.

The school nurse is bringing a group of students to a nursing home for a social exchange project. Before the students arrive, the nurse reminds them to do what when speaking to the residents? 1. Speak as loud as they can. 2. Speak into the residents' ears. 3. Write out what they want to say on a piece of paper. 4. Speak distinctly, while facing the residents.

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? a. Client will ambulate without a walker by 6 weeks. b. Client will ambulate freely in house. c. Client will not fall. d. Client will have freer movement in daily activities.

In Ackley (Nursing Diagnosis textbook) it states when writing outcomes/goal statements - using the acronym SMART is helpful. What does the acronym SMART stand for? (Ackley pg 8)

The SMART acronym is used in business, education, and health care settings. This method assists the nurse in identifying patient outcomes more effectively." It stands for Specific, Measurable, Attainable, Realistic, and Timed. (Ackley, pg.8)

1) The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? a. Burns b. Drowning c. Poisoning d. Suffocation

11. The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the client's coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? a. Strengths can be an aid to mobilizing health and the healing process. b. The client will be more active in the plan. c. It will be easier for the nurse to educate the client about other interventions. d. The nurse won't have to spend time going over the pathology of the client's disease.

12) While irrigating a client's abdominal wound, the irrigate splashes into the nurse's nose and eyes. What should the nurse do? a. Flush the nose and eyes for 5-10 minutes with water or normal saline. b. Begin HIV high-risk exposure prophylaxis within 24 hours. c. Wash the areas with soap and water. d. Have blood drawn for hepatitis B antibodies.

16) The nurse is creating a teaching poster about the most recent National Patient Safety Goals. Which information should be included to reduce the risk of healthcare-associated infections? a. Post the guidelines for hand hygiene b. List the chemicals used to clean the floors c. Identify when the client rooms are cleaned each day d. Explain the different types of transmission-based precautions

The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? a. Place the leg band on the client with the leg in a straight horizontal position. b. Place the sensor under the mattress near the shoulder region. c. Set a time delay for 30 seconds. d. Connect the sensor pad to the control unit.

5. The nurse is providing care to an assigned client. Which action indicates that the nurse supports the client's respect for dignity? a. Allowing the client to complete hygienic care when possible b. Providing all care to the client whenever possible c. Telling the other staff that the client is demanding, so they are able to meet the client's needs d. Presenting information to the client's family about the client's condition

The nurse is making an occupied bed. Which step will provide comfort for the client during this linen change? a. Loosen the covers around the foot of the bed. b. Place a bath blanket over the client. c. Slide the mattress to the head of the bed. d. Raise the side rail.

8) A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? a. Have the client wear a mask when coming from admission. b. Stock the supply cart at the beginning of each shift. c. Wash the hands only after leaving the room. d. Wear a mask when exiting the room.

9) The nurse is assessing a client's blood pressure. What should the nurse hear during phase 2 of Korotkoff's sounds? a. A muffled, whooshing, or swishing sound b. Disappearance of sound c. Faint, clear tapping sound d. Increased intensity of sound

A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? a. Standardized care plans b. Traditional care plans c. Critical pathways d. Kardex

A child is starting school and is being screened for certain developmental milestones. What is the nurse assessing when determining how the child interacts with other children? a. Temperament b. Physical characteristics c. Environment d. Culture

A client has a hearing aid with an earpiece that is almost invisible to an observer. The nurse would document this as which type of hearing aid? a. Body hearing aid b. In-the-canal aid c. Completely-in-the-canal aid d. Eyeglasses aid

A client has a reddened area over the coccyx that disappears after an hour. In which way should the nurse document this area? a. Reactive hyperemia b. Stage 1 pressure injury c. Stage 2 pressure injury d. Stage 3 pressure injury

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores? a. Trending can only be accurate if the same scale is used. b. There is a definite trend of low risk for pressure injury development. c. Trending would be more accurate if the same scale was used. d. The scores indicate opposite risks for pressure ulcer development.

A client has the goal statement "Client will have clear lung sounds bilaterally within 3 days." One intervention to meet this goal is for the nurse to teach the client to cough and deep-breathe and have the client do this several times every 2 hours. At the end of the third day, the client's lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? a. Ask how many times per day the client practiced the coughing and deep-breathing exercises. b. Tell the client that the lungs are clear. c. Document the assessment findings to show the effectiveness of the intervention. d. Write this evaluation statement: Goal met, lung sounds clear by third day.

A client is in the critical care unit for an acute illness. Which type of bath should this client receive? a. Bag b. Towel c. Self-help d. Complete

A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. a. Pad bony prominences on the wrist. b. Apply the padded portion of the restraint around the wrist. c. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. d. Attach the other end of the restraint to the movable portion of the bed frame using a half- bow knot.

A client is removing soft contact lenses. Which should the nurse do to support the client's lenses? a. Provide disposable tissues b. Obtain a bottle of sterile normal saline c. Remind to place each lens in the correct side of the container d. Prepare to irrigate the client's eyes after removal

A client reports having a severe sunburn after being outdoors for a short period of time. For which potential cause should the nurse assess the client? a. Takes an antibiotic b. Eats fresh fruit everyday c. Sleeps 7 hours each night d. Exercises 5 days a week

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? a. Anxiety b. Acute Pain c. Social Isolation d. Low Self-Esteem

A client who is unmarried and has one child reports living with another single person who has two children. Which type of living arrangement does this client have? a. Cohabiting family b. Blended family c. Foster family d. Intragenerational family

A client with an aquathermia pad reports that the pad is not warm after 15 minutes and wants the temperature increased. How should the nurse evaluate this request? a. Because this client's thermal tolerance is higher than normal, increasing the temperature is necessary. b. This client may be experiencing a rebound effect from the application of moist heat. c. Adaptation of the thermal receptors often results in the decreased sensation of warmth. d. The aquathermia pad should be replaced with a standard hot pack.

A client's hearing aid needs to be removed. What action should the nurse perform? a. Assist the client with removal when necessary. b. Instruct the client to remove the aid in the sunroom. c. Leave the aid in place when bathing. d. Send the aid home with the family.

A client's laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing? a. Primary intention b. Open approximation c. Secondary healing d. Delayed closure

A family struggles with clear communication, and members of the family often seek the help of other systems for personal validation and gratification. What should the nurse identify as an appropriate nursing diagnosis for this family? a. Altered Family Processes related to communication patterns b. Impaired Verbal Communication related to inability to communicate c. Ineffective Family Coping evidenced by assistance from outside sources d. Knowledge Deficiency (communication patterns) related to dysfunctional patterns of communication

A father of a family was killed in a motor-vehicle crash. What should the nurse consider a "normal" reaction to this event? a. Family disorganization may occur. b. Family members become detached from extended family. c. The family feels that their place in the community has been eliminated. d. The family withdraws into seclusion during the grief process.

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? a. The client's record contained an incorrect DRG. b. The client was charged for an ECG. c. A code cart was opened and the client was charged for medications opened but not used. d. The physician made a diagnostic mistake.

After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? a. The ones that the nurse is licensed to treat b. The ones that address other health professionals' interventions c. The ones that focus on the client's primary illness d. The ones that have standardized care available

During morning care, assistive personnel (AP) note that a client's wound is seeping a large amount of drainage. Which should the AP do? a. Notify the nurse. b. Remove the dressing. c. Apply a new dressing. d. Reinforce the dressing.

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60-90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? a. 60-90 degrees during feeding times b. Position in chair c. Upright in a chair d. Impaired swallowing

The client's lab studies reveal a normal serum albumin with a prealbumin of 10. How should the nurse interpret the significance of these readings? a. The client has had recent protein malnutrition. b. The client is now relatively well nourished with malnutrition 6-8 months ago. c. The client is at risk for development of malabsorption syndromes. d. Carbohydrate malnutrition has occurred over the last 6 months.

The nurse identifies the diagnosis of Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia for a client newly diagnosed with pancreatic cancer. What is the etiology of this diagnosis? a. Unfamiliarity of disease process b. Anxiety c. Restlessness d. Tachycardia

The nurse is assessing an older client. Which finding should cause the nurse to be concerned about the client's safety? a. Alteration in olfactory status b. Blood pressure 138/88 mm Hg c. Applies medication for a skin rash d. Ambulates without assistive devices

The nurse is assessing the cognitive development of an adolescent. Which finding indicates that the client is in the formal operations stage of cognitive development? a. Thinks abstractly b. Spends times with peers c. Engages in organized sports d. Decides differences are wrong

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected? a. Clean areas of granulation tissue b. Exudate in the bottom of the wound c. A pus-coated area on the side of the wound d. Intact skin at the edge of the wound

The nurse is planning care for a client with urinary frequency. Which action should be taken to reduce the client's risk of falling when walking to the bathroom? a. Provide a bedside commode b. Raise one side rail on the bed c. Assess for activity intolerance d. Provide slippers with nonskid soles

The nurse is preparing to measure a client's temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? a. Assess that the equipment used is working properly. b. Place the client in a position that is most comfortable for the healthcare provider. c. Take the temperature with a chemical disposable thermometer when the client is perspiring. d. Wait at least 10 minutes before taking the temperature after a client has been smoking.

The nurse is reviewing assigned clients for morning care needs. Which situation could pose a threat to one client's personal hygiene? a. A client has a newly formed ileostomy. b. A client performs meticulous foot care. c. A German client refuses to bathe every day. d. The room temperature is set at 72°F

The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? a. Always pull a plug at the plug-in from the wall outlet. b. Keep plants in the home. c. Use overloaded outlets when necessary. d. Remove labels from containers and refill for recycling.

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing? a. Materials used in dressing this wound should keep the wound bed moist. b. The dressing should allow good air circulation through the wound. c. Dressings should be simple as they will be changed at least every 4 hours. d. Absorbent material to wick exudates away and support drying should be used.

The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: a. Yield a falsely high blood pressure. b. Yield a falsely low blood pressure. c. Be the same, regardless of cuff size. d. Vary as a result of the technique of the person performing the assessment.

The nurse selects the nursing diagnosis of Willingness to learn about spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? a. The family visits different congregations, the parents have been reflecting on their ownspiritual upbringings, and the children are questioning rituals of their friends and friends' families. b. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. c. The grandparents go to weekly services and have formal interaction with clergy. d. The children have attended private, religious schools, and the parents are involved in the school's activities.

The parents of a school-age child are concerned about the child learning right from wrong. In which order should the nurse explain that moral development will develop in the child? a. Punishment and obedience b. Law-and-order orientation c. Instrumental—relativist orientation d. "Good boy—nice girl" stage

The school health nurse is identifying education programs for high school students besides the dangers of unprotected sex or drug and alcohol abuse. Which class topic should the nurse present to these students? a. Warning signs of depression for peers to identify among their classmates b. Injury prevention c. Early signs of cancer and heart disease d. Normal physiological changes of this age group

A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence? (Select all that apply.) a. A root cause analysis b. Paperwork about a sentinel event c. Analysis of the nurse assigned to the client d. Number of times the client was observed on the night shift e. Number of hours since the client last received pain medication

a,b

14) The nurse is planning to assess a client's pulse. What characteristics should the nurse include in this assessment? (Select all that apply.) a. Rate b. Rhythm c. Volume d. Tone e. Viscosity

a,b,c

7) The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? (Select all that apply.) a. Client is receiving intravenous fluids. b. Client has an indwelling urinary catheter. c. Client is recovering from surgery. d. Client is receiving pain medication. e. Client is ambulating twice a day with assistance

a,b,c

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? (Select all that apply.) a. Intact and dry skin b. Intact oral mucous membranes c. Bowel sounds present in all four quadrants d. Nasal congestion e. Urinary retention

a,b,c

When assessing a client's respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? (Select all that apply.) a. Oxygen concentration b. Carbon dioxide concentration c. Hydrogen ions d. Potassium level e. Serum calcium level

a,b,c

10. During a family assessment, the nurse determines that a family functions according to the systems theory. What did the nurse assess to make this clinical decision? (Select all that apply.) a. Family members work together toward goals. b. Family members seek out and use community resources. c. Family members interact with other community systems. d. Healthy boundaries are used to regulate influence by other systems. e. Family members are encouraged to hold fast to beliefs and practices.

a,b,c,d

A client diagnosed with an infectious disease asks the nurse how the infection "got inside" her body. Which responses would be appropriate for the nurse to make? (Select all that apply.) a. "It depends on the number of organisms present to cause a disease." b. "It depends on how aggressive the organisms are to cause a disease." c. "It depends on how the organisms get inside the body to cause a disease." d. "It depends on where the person is at the time the disease is present." e. "It depends on where the person works."

a,b,c,d

The nurse is assigning feedings of an older client who is at risk for aspiration to assistive personnel (AP). What feeding techniques should the nurse instruct the AP to use? (Select all that apply.) a. Thicken all fluids. b. Use the chin-tuck method. c. Place the client in a seated position. d. Focus on food preferences. e. Keep the head of the bed at a 30-degree angle.

a,b,c,d

The nurse is planning an educational program for community members on ways to improve nutritional intake. What information should the nurse include about carbohydrate digestion and metabolism? (Select all that apply.) a. Enzymes are needed to digest carbohydrates. b. The breakdown of carbohydrates results in simple sugars. c. Carbohydrates are a major source of body energy. d. The simple sugar glucose provides a readily available source of energy. e. Pancreatic amylase enhances the use of glucose by the body cells.

a,b,c,d

The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process? (Select all that apply.) a. Effectively assessing the client's needs b. Selecting the appropriate nursing diagnosis related to the client's needs c. Collecting client-focused data with a specific need in mind d. Evaluating by using assessment data to determine effective achievement of goals and outcomes e. Basing evaluation on assessment data collected during the admission phase

a,b,c,d

The nurse is reviewing care planned for a client. For which reason should the nurse complete daily planning for this client? (Select all that apply.) a. Identify issues that are no longer client problems b. Set priorities for the client's care during the shift c. Determine if the client's health status has changed d. Decide which problems to focus on during the shift e. Coordinate activities so several problems can be addressed at each contact

a,b,c,d

11. The nurse manager is preparing a teaching tool about the nursing process. Which activities should the manager identify that are completed during the planning phase of the process? (Select all that apply.) a. Cluster data b. Identify actions c. Problem solving d. Decision making e. Evaluate outcomes

a,b,c,d,e

16) The school nurse determines that a 14-year-old student has reached an expected level of cognitive development. What did the nurse assess to come to this conclusion? (Select all that apply.) a. Thinks logically b. Thinks about the future c. Makes rational statements d. Uses a trial-and-error process e. States things as they could be

a,b,c,e

The nurse is planning to use the structural-functional theory when assessing a family new to a community. What should the nurse include when conducting this assessment? (Select all that apply.) a. Individuals in the family b. The family's sense of purpose c. Relationships among family members d. Strategies to restrict outside influences on the family e. The approach the family uses to socialize new family members

a,b,c,e

The nurse is preparing to provide a morning bath to a client diagnosed with dementia. What can the nurse do to ensure a positive bathing experience for the client? (Select all that apply.) a. Move slowly. b. Be flexible. c. Help the client feel in control. d. Avoid stopping once the bath is started. e. Be prepared.

a,b,c,e

6. A family member is hospitalized with an illness. What should the nurse assess to determine the impact this illness will have on the family? (Select all that apply.) a. Nature of the illness b. Duration of the illness c. Cause of the illness d. Financial impact of the illness e. Effect of the illness on future family functioning

a,b,d

A client reports that an adolescent family member has started a vegan diet. Which additions to meals should the nurse recommend to help ensure that the adolescent does not become deficient in calcium? (Select all that apply.) a. Tofu b. Soybeans c. Brewer's yeast d. Raisins e. Okra

a,b,d

The nurse is confident that a client has met the developmental guidelines for a preschooler. What did the nurse assess to make this clinical decision? (Select all that apply.) a. Can print her own name. b. Proudly announces, "I put my own toys away." c. Shares that, "I know I shouldn't hit, even when I'm mad." d. Effectively brushes her own teeth. e. Washes her hands after toileting without prompting.

a,b,d

The nurse is preparing to assess a family regarding the impact of one of its members being diagnosed with diabetes. What should the nurse include in this assessment? (Select all that apply.) a. The seriousness of the disorder b. Whether the family has ever dealt with a chronic illness before c. The age of the affected member d. The financial impact the illness will have on the family e. The number of members of the family

a,b,d

A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linens? (Select all that apply.) a. Pulse b. Respirations c. Urine output d. Blood pressure e. Mobility status

a,b,d,e

The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client? (Select all that apply.) a. Congruent with the client's values, beliefs, and culture b. Are within established standards of care c. Based on scientific and medical knowledge d. Achievable with the resources available e. Must be safe and appropriate for the client's age

a,b,d,e

The nurse is planning instruction for a client who is underweight. What should be included in this teaching? (Select all that apply.) a. Discuss factors contributing to inadequate nutrition and weight loss. b. Discuss ways to manage, minimize, or alter the factors contributing to malnourishment. c. Discuss principles of a well-balanced diet and high-and low-calorie foods. d. Provide information about community agencies that can assist in providing food. e. Provide information about ways to increase calorie intake.

a,b,d,e

The nurse is planning to complete a family assessment. For which reasons is the nurse completing this assessment? (Select all that apply.) a. Determine the level of family functioning. b. Identify family strengths and weaknesses. c. Provide legal guidelines for consent to healthcare. d. Clarify family interaction patterns. e. Describe the health status of individual members

a,b,d,e

The nurse is preparing a teaching session for a group of parents with newborn children. What should the nurse include about Bowlby's attachment theory during this presentation? (Select all that apply.) a. Use the attachment figure as security b. Desire to be near the attachment figure c. Plan to separate from the attachment figure d. Return to the attachment figure when threatened e. Express anxiety when the attachment figure is absent

a,b,d,e

The nurse is confident that a family is functioning appropriately. What findings did the nurse use to make this determination? (Select all that apply.) a. The teenage son keeps the money earned from cutting grass for a "car fund." b. All the children are expected to excel in the sport of their choice. c. A parent reads the preschool child a bedtime story each night. d. All the children have household chores once they reach school age. e. A young adult child moves back home after losing his job.

a,c,d

A client comes to the emergency department with a temperature of 104°F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? (Select all that apply.) a. 1. Delirious b. Pale and dizzy c. Skin warm and flushed d. No evidence of sweating e. Had been playing tennis in the sun

a,c,d,e

The nurse is appointed to be a member of a committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? (Select all that apply.) a. Lifting clients b. Inadequate lighting c. Bending and walking d. Exposure to infectious agents e. Exposure to hazardous medications

a,c,d,e

The nurse is instructing a client on foods that are considered complete proteins. What will the nurse include in these instructions? (Select all that apply.) a. Meat b. Gelatin c. Eggs d. Chicken e. Fish

a,c,d,e

The nurse wants to assess a client during the morning bath. What will the nurse be able to assess during this time? (Select all that apply.) a. Skin status b. Financial status c. Psychosocial needs d. Learning needs e. Physical conditions

a,c,d,e

6. The nurse is reviewing assessment data collected for a client's care plan. What criteria should the nurse use when formulating this client's nursing diagnoses? (Select all that apply.) a. Nonjudgmental statements b. Stated in terms of a need c. Must be legally advisable d. Cause/effect correctly stated e. Medical terminology used to describe the cause f. Diagnosis worded specifically and precisely

a,c,d,f

The nurse is discussing human growth and development with the parents of a newborn. What should the nurse include in this discussion? (Select all that apply.) a. Growth involves physical change and increase in size. b. Skills and function increase with growth. c. Most humans experience a similar pattern of growth. d. Being able to adapt to one's environment is an indicator of growth. e. Children's growth is monitored by height, weight, bone size, and dentition.

a,c,e

The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? (Select all that apply.) a. Triclosan b. Chlorine (bleach) c. Isopropyl alcohol d. Hydrogen peroxide e. Chlorhexidine gluconate

a,c,e

The nurse is planning care for a client. For which reason should the nurse identify desired outcomes before identifying interventions? a. Provide direction b. Provide a sense of achievement c. Determine when problems are solved d. Identify criteria for evaluating progress

a,d

The nurse is using the PES model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? (Select all that apply.) a. Ineffective coping related to depression as evidenced by suicide attempt b. Noncompliance (DASH diet) related to denial of having disease c. Risk for infection related to recent surgery d. Nutrition less than adequate related to anxiety as evidenced by weight loss of 10 pounds e. Ineffective Breathing Pattern as evidenced by cyanotic lips

a,d

The nurse wants to adhere to practice guidelines that meet legal and ethical standards when documenting client care. Which actions should the nurse take to prove adherence? (Select all that apply.) a. Charting the client's response to pain medication taken b. Describing the client as "appearing to be comfortable" c. Leaving sufficient charting space for the previous shift to chart client teaching d. Documenting that the client reports, "I'm so afraid of tomorrow's surgery" e. Making a late entry regarding a client's request for pain medication

a,d,e

A client asks the nurse for help in selecting foods, as some are "good" and others are "bad." How should the nurse respond to the client? (Select all that apply.) a. "Eat a wide variety of foods to furnish adequate nutrients." b. "Avoid starchy foods." c. "Limit foods with high-fructose corn syrup." d. "Eat three meals a day to reduce calories." e. "Eat moderately to maintain correct body weight."

a,e

The nurse is assessing a client. For which health problem should the nurse choose the dorsalis pedis pulse as the site for further assessing the client's status? a. Altered level of consciousness b. Decreased urine output c. Irregular radial pulse d. Toes cool to touch

11) A client is prescribed seizure precautions. What can the nurse safely assign to assistive personnel (AP) to complete when implementing the precautions? a. Placing a tongue blade at the head of the bed b. Padding the client's bed a. Installing oxygen c. Checking the oral suction apparatus

11) A client with an acute, serious illness is observed praying. With which theorist should the nurse associate this client's behavior? a. Fowler b. Westerhoff c. Gilligan d. Kohlberg

12) The nurse documents that a client's postoperative wound is purosanguinous. What did the nurse assess in this client's wound? a. Water and red blood cells b. Pus and red blood cells c. Watery drainage d. Pus

12. A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? a. Pain due to unknown factors b. Pain related to unknown etiology c. Pain caused by psychosomatic condition d. Pain manifested by client's report

13) A client is prescribed to be out of bed three times a day. In which way should the nurse document this activity level? a. OOB tid b. OOB 3 x /day c. Out of bed T.I.D. d. OOB three times a day

13. After communicating with the client and family, the nurse compares a client's problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? a. Understanding what is normal versus what is not normal b. Verifying c. Consulting resources d. Basing diagnoses on patterns

22) An adolescent spends large amounts of time with friends, causing the parents to have concern. What should the nurse respond to the parents? a. "You should really keep better track of your child. It's hard to tell what kinds of trouble she may be getting into." b. "Independence is really important for this age group. Try to be extra attentive when your child does spend time at home." c. "Use stricter guidelines for curfew and punishment if curfew is broken." d. "Is it possible that your child might be taking drugs?"

A child is learning new words faster than he can write them in the baby book. According to Piaget, the nurse realizes that this child is in which phase? a. Intuitive thought phase b. Preconceptual phase c. Concrete operations phase d. Formal operations phase

A client diagnosed with negative nitrogen balance abstains from all food for several days at a time. What should the nurse discuss with the client regarding this practice? a. The amount of weight the client will lose during the fasts b. The need to ingest some carbohydrates for body functions c. The amount of calories the client will need to ingest after fasting for several days d. The importance of the practice to the client

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client's problem? a. Encourage the client to eat at least 40% of meals. b. Keep linens dry and wrinkle-free. c. Restrict fluid intake. d. Turn client every 3 hours.

A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do? a. Follow the physician's orders as written and give the medication. b. Call the pharmacy and do further investigating before administering the medication. c. Ask the client about this medication. d. Call the physician and ask what the medication is and what it is for.

A client is prescribed steroid medication. For which reason should the nurse instruct the client about infection control because of this medication? a. Decreases oxygen supply to tissues b. Suppresses the inflammatory process necessary for healing c. Decreases the amount of nutrients such as glucose in the blood d. Constricts blood vessels, which impairs waste product removal

A client who has not been bathed for several days does not want to get into the tub for a morning bath. What should the nurse do? a. Assign assistive personnel the task of giving the client a bath. b. Skip the client's bath and document "refused" in the medical record. c. Ask the client the usual way bathing occurs at home. d. Tell the client that a bath is needed and ignore the client's comment.

A client who is being transferred to a rehabilitation center wants to take the medical record to the new facility. How should the nurse respond to this client's request? a. "You'll have to ask your doctor for permission to do that." b. "Actually, the original record is the property of the hospital, but you are welcome to copies of your records." c. "We'll make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details." d. "There's a new law that protects your records, so you're not going to be able to have access to them."

A client with a terminal diagnosis collects pictures for a scrapbook and wrote a journal of favorite memories for family members to read after the client dies. According to Peck, the nurse realizes that this client is working through which developmental task? a. Body transcendence versus body preoccupation b. Ego transcendence versus ego preoccupation c. Ego differentiation versus work-role preoccupation d. Integrity versus despair

A connection on a client's intravenous solution was dislodged and solution saturated the client's gown and bed linens. The nurse will provide which type of hygienic care to the client? a. Hour-of-sleep care b. As-needed care c. Early-morning care d. Morning care

An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this client's plan of care? a. The client's eyes are closed. b. The client's skin is pale and mottled. c. The client's spouse is asleep in the chair next to the bed. d. The television is on and the volume is turned up.

During a wellness visit, the nurse notes that a 16-month-old child is unable to move from a sitting to a standing position. In which process should the nurse identify that this child is lagging? a. Growth b. Development c. Height d. Behavior

Nitrogen balance testing is planned for a client. What instruction to the staff caring for this client is essential? a. Remove the client's oxygen cannula 10 minutes prior to the test. b. Accurate measurement of food intake is very important. c. All urine output should be collected for 48 hours. d. Keep the client NPO beginning at midnight before the test.

On the fourth postoperative day, a client has a sudden coughing episode and reports that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first? a. Notify the client's surgeon. b. Cover the area with a large saline-soaked dressing. c. Position the client in bed with knees bent d. Pack the wound with nonadherent gauze.

The client is weighed each month while residing in the long-term care facility. This month the client weighs 110 lb (50 kg). The nurse compares this weight to the last 3 months' results and discovers the client has lost 22 lb (10 kg). There has been no attempt to lose this weight. How should the nurse interpret this weight loss? a. No malnutrition b. Mild malnutrition c. Moderate malnutrition d. Severe malnutrition

The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? a. Plan b. Intervention c. Evaluation d. Progress notes

The nurse assigns assistive personnel (AP) to provide morning care to a client. Which information is essential for the nurse to provide to the AP? a. Blood test results b. Any precautions to take c. Reason for a chest x-ray d. Marital status of the client

The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? a. Becoming ill with tetanus and receiving tetanus toxoid b. Having chickenpox c. Receiving a rabies shot after being bitten by a rabid dog d. Receiving an injection of gamma globulin

The nurse formulates the nursing diagnosis of Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? a. Provide a calm, quiet atmosphere in the client's room. b. Administer pain medication. c. Educate the client and family regarding treatment and therapies. d. Monitor for changes in the client's condition.

The nurse has assigned administration of tube feeding to a specially unlicensed trained assistive personnel (UAP). What action should be taken by the nurse in regard to this delegation? a. Order the equipment to give the feeding. b. Check the tube for placement. c. Set up the equipment and mix the feeding. d. Regulate the rate of the feeding.

The nurse has completed foot care for a client as part of routine morning care. What should the nurse document about the procedure? a. The condition of the skin and nails b. Nothing unless a problem is noted c. The amount of time taken on foot care d. The client's comments about the foot care

The nurse is assessing a client's peripheral pulse. Which characteristic should the nurse also assess at this time? a. Depth b. Rhythm c. Sound d. Stress

The nurse is assessing a preschool-age child. Which behavior indicates that the client is successfully in the stage of initiative versus guilt? a. Becomes upset with failure b. Imitates a parent's behavior c. Cries when the mother leaves the room d. Argues about spending time with friends

The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? a. Assign this client to the farthest room from the nurses' station. b. Place a rocking chair in the client's room. c. Pull up all of the side rails on the bed. d. Wedge pillows against the side rails on the bed.

The nurse is caring for a client with Parkinson disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client? a. Provide assistance as needed with dressing and grooming. b. Provide assistive devices and educate client to use grab bar and large-handled utensils. c. Make sure lighting and space are adequate for client. d. Administer medications to improve muscle tone.

The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client? a. Cut toenails in a rounded shape and file. b. Dry toes thoroughly. c. Wash feet with water at a temperature of 90-98.6°F. d. Inspect feet thoroughly once a week.

The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? a. The client will demonstrate an understanding of all limitations. b. The client will establish a buddy system. c. The client will make uninformed choices when addressing health issues. d. The client will take his medication as desired.

The nurse needs to assess a client's respiratory status. Which client position would be the best for this assessment? a. Prone b. Semi-Fowler c. Side-lying d. Supine

The nurse notes that a client has the outcome goal "Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic." Which client statement should the nurse use to evaluate this goal? a. "I'm getting really sleepy from that medication. I think I'll take a nap." b. "My pain is a 4." c. "I still have some pain." d. "Will the pain ever go away?"

The nurse notes that the tube-fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What should the nurse do first? a. Place the client in high Fowler position. b. Turn off the tube feeding. c. Assess the client's lung sounds. d. Assess the client's bowel sounds.

The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients? a. Cognitive b. Interpersonal c. Technical d. Therapeutic

The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention? a. Assist client with ambulation. b. Ambulate with client, using a gait belt, twice daily for 15 minutes. c. Make sure client understands the rationale for using the gait belt. d. Client will ambulate in hallway twice daily. Rationale & Reference: "Nursing interventions include both direct and indirect care, as

The nurse is preparing to apply a bandage to a client using the spiral reverse turn. For which body parts should the nurse use this technique when bandaging? (Select all that apply.) a. Finger b. Forearm c. Upper leg d. Lower leg e. Upper arm

b,c

The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? (Select all that apply.) a. The system is relatively inexpensive to maintain. b. Bedside terminals eliminate worksheets and note taking. c. The system links to various sources of client information. d. The system better protects client privacy. e. Information is legible. f. Results, requests, and client information can be sent and received quickly.

b,c,e,f

A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this client's wound? (Select all that apply.) a. Cover it with transparent film. b. Apply a damp-to-damp normal saline dressing. c. Cover it with a dry dressing. d. Irrigate the wound.

b,d

The nurse is reviewing the four stages of development in Westerhoff's spiritual theory. In which order should the nurse review these stages to match the life cycle? a. Owned faith b. Affiliative faith c. Experienced faith d. Searching faith

b,d,a,c

The nurse manager has been appointed to implement a quality assurance program at the hospital. Which components should the manager prepare to evaluate for this program? (Select all that apply.) a. Methods b. Structure c. Finances d. Process e. Outcome

b,d,e

14) The nurse visits the home of a client recently hospitalized. Which finding indicates to the nurse that the client is at risk for injury in the home environment? a. Handrails on all stairs b. Nonskid shower surface c. Outdoor lightbulbs burned out d. Smoke alarms throughout the home

14. After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the client's laboratory values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? a. Verify the information with the client. b. Compare all findings to the national norms and standards. c. Consult other professionals and colleagues. d. Improve critical thinking skills so answers come more easily.

17) The nurse notices that the client's continuous open-system tube-feeding set is almost empty. What action should the nurse take? a. Add tube feeding to the set. b. Discontinue the feeding and hang a closed system bag. c. Wash out the set and add new feeding. d. Flush the set with clear carbonated soda and discontinue.

2. A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this client's care? a. Informal nursing care plan b. Formal nursing care plan c. Standardized care plan d. Individualized care plan

3) As a member of the safety committee, the nurse's task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? a. Display the phone number to the nurses' station. b. Keep electrical cords under the bed. c. Keep the environment tidy. d. Read label directions.

4. The nurse has formulated the diagnosis of Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? a. Activity intolerance b. Weakness and debilitation c. Reports of fatigue d. Physical activity

5) The nurse asks unlicensed assistive personnel (UAP) to help a client off of a bedpan. Which action should the UAP take first? a. Wash hands b. Apply gloves c. Apply a gown d. Apply a face mask

5) The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? a. Leave the areas blank. b. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. c. Write N/A on the flow sheet in the areas that are not applicable to that client. d. Make sure this information gets passed along in the shift report.

5. The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy? a. Nursing diagnosis statement b. Planning portion of the care plan c. Goal statement of the traditional care plan d. Implementation phase of the care plan

A client has hard contact lenses. What should the nurse do to assist the client in the care of the lenses? a. Pinch the lenses out of the client's eyes to remove. b. Remove both of the client's lenses before storing in the appropriate storage cup. c. Document when the lenses need to be removed and cleaned every 2 weeks. d. Ask the client how many hours the lenses are worn each day.

A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this client's care? a. The admitting nurse b. All nurses who work with the client c. Everybody involved in this client's care d. The client and the client's support system

A client is having a lumbar puncture at the bedside. Which action should the nurse assign to unlicensed assistive personnel (UAP) to complete? a. Apply sterile gloves b. Clean a work surface c. Open the sterile package d. Transport samples to the lab

A client who has undergone gastrointestinal surgery is permitted to have a clear liquid diet on the second postoperative day. Which fluid should the nurse order from the diet kitchen for this client? a. Apricot nectar b. Cranberry juice c. Chicken broth d. Cherry ice pop

A toddler shows fear and begins to cry when left at day care. According to Havighurst, which developmental task should the nurse recognize this child is exhibiting? a. Building wholesome attitudes toward oneself b. Learning to get along with age-mates c. Learning to relate emotionally d. Achieving personal independence

A trauma victim's leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take? a. Place a tourniquet above the wound. b. Remove the dressing and place direct pressure on the wound. c. Add an additional dressing to the wound without removing the original. d. Remove the dressing and replace it with a new sterile dressing

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it's permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? a. "Confidentiality and privacy laws don't apply to students." b. "Most students review so many records and charts that they could not possibly remember details from any one of them." c. "Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence." d. "As long as the clinical instructor is in the area, accessing client records is part of the education process."

An older client is agitated and confused after relocating to a new facility. Which action should the nurse take to ensure for this client's safety? a. Apply a vest restraint b. Medicate with a sedative c. Take the client for a walk d. Place in a chair with a locked tray

An older client who is incontinent and wears incontinence briefs develops an irritated rash in the perianal area. What care should the nurse provide? a. Wash the area with soap and hot water at every brief change. b. Apply a petroleum-based cream to the area after cleaning. c. Wipe the skin with an alcohol-free barrier film agent after cleaning. d. Keep the client in bed on absorbent pads until the area clears.

Assistive personnel (AP) reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound the nurse should take which action? a. Obtain a transparent dressing for the AP to place on the wound. b. Request a consult with the wound care nurse. c. Cleanse the wound and apply a dressing. d. Tell the AP to reevaluate the wound in 20 minutes

During a home visit, a client reports feeling sad and upset about personal appearance. For which reason should the nurse assist the client with a bath? a. Improve circulation b. Establish trust with the client c. Improve morale and self-concept d. Remove dead skin cells and bacteria

In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? a. When the cuff is applied b. When the cuff is being deflated c. When the first pulsation is felt d. When the second pulsation is felt

On admission, the client weighs 165 lb (75 kg). The client reports that this is a weight loss from 180 lb (82 kg). What is this client's percent weight loss? a. 4.5% b. 6.25% c. 8.3% d. 10.0%

The client had diminished wheezing in both lungs after receiving emergency treatment for an acute asthma attack. When utilizing focus charting, in which section should the nurse document this information? a. Data (D) b. Action (A) c. Response (R) d. Planning (P)

The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? a. Depend on knowledge gained from peers' experiences. b. Work with seasoned and experienced nurses and learn from them. c. Take assessment notes and utilize information from textbooks for comparison. d. Know that this will take time, and experience is the best teacher.

The nurse assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? a. Ask another nurse to assess the pulses. b. Document the findings. c. Obtain a Doppler ultrasound stethoscope. d. Wait and try again later.

The nurse changes the dressing around a client's drain. Which information can be omitted from the documentation of this care? a. Condition of the skin b. Condition of the drain c. Name of the surgeon who inserted the drain d. Estimated amount of drainage on the dressing

The nurse has assigned the making of unoccupied beds to assistive personnel. What should the nurse assess regarding client safety once the beds are completed? a. Folding of the top sheet b. Direction of the pillow c. Call light being readily available d. Presence of mitered corners

The nurse has instructed an overweight client to follow a 2,000-calorie diet by substituting foods considered low in calories for those higher in calories. How should the client interpret the food label to decide if a food is moderate in calories? a. The product label will state "lighter" or "reduced calories." b. The Nutrition Facts label will have the letter "L" located in the lower right corner. c. Nutritional labeling on the product will indicate 100 calories per serving. d. The product will contain no more than 11% fat.

The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale? a. Have suction equipment available at all times. b. Clear secretions from oral/nasal passageways as needed. c. Keep client in low-Fowler position to prevent reflux.

The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? a. The client will be able to name the staff that works on the day shift. b. The client will eliminate safety hazards in her environment. c. The client, with supervision, will brush the teeth. d. The nurse will stress the importance of adequate fluid intake.

The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? a. Keep clutter to a minimum in the client's room. b. Have the client wear terry-cloth slippers. c. Provide adequate lighting. d. Turn off alarms to reduce noise.

The nurse is asked to explain why so much time is spent on the assessment, diagnosing, and planning phases of the nursing process. Which response should the nurse make? a. "They eliminate the need to reassess the client." b. "They make it easier to provide care to the client." c. "They help determine if the client has achieved outcomes." d. "They provide the basis for the actions performed during the implementation phase."

The nurse is assigning assistive personnel (AP) to provide care to a group of clients. For which client reason should the AP provide mouth care more frequently? a. Has a nasogastric tube b. Treatments for diabetes c. Medications for osteoarthritis d. Receives intravenous antibiotics

The nurse is exploring the behavior of children and how they interpret right from wrong or bad from good. Which theorist should the nurse study to learn this information? a. Vygotsky b. Skinner c. Kohlberg d. Piaget

The nurse is making a client's bed. What safety measure should the nurse implement at this time? a. Begin at the head and move toward the foot, loosening the bottom linen. b. Miter corners at the head of the bed. c. Place the soiled sheet in a laundry bag. d. Prepare the client.

The nurse is performing a family risk assessment. Which factor should the nurse identify that indicates this family is at risk of developing health problems? a. The family is an elderly couple who are active in their retirement community. b. The family is a teenage mother and child. The mother is enrolled in parenting classes at the high school. c. The family belongs to the local synagogue and has family members still living in Germany. d. The family depends on two incomes with a limit on their health insurance spending.

The nurse is plotting the height and weight of children during a school assessment clinic. Which aspect of the children's health is the nurse assessing? a. Development b. Health c. Growth d. Bone size

The nurse is preparing to bathe a client on the first postoperative day. Which nursing intervention should take priority? a. Apply lotion to the extremities. b. Change the water when it becomes cold. c. Raise side rails when gathering supplies. d. Remove the soiled dressing during the bath

The nurse is preparing to provide hygienic care to a client. On what will the nurse focus this care? a. Clothes b. Family c. Hair d. Nutritional

The nurse is preparing to shave a client. Which action step should the nurse consider when providing this care? a. Assist the client to a prone position. b. Pull the skin taut with the dominant hand. c. Wear gloves during the procedure. d. Use long strokes

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? a. Database b. Problem list c. Plan of care d. Progress notes

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? a. Mental status of the client b. Chronic nature of the illness c. Nursing care focus d. Prognosis

The nurse is shampooing a client's hair. Which assessment finding should the nurse consider as expected? a. Dry, dark, thin b. Smooth, taut, shiny c. Smooth texture and not oily or dry d. Tender, warm scalp

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin? a. Keep the head of the client's bed at 30°F. b. Coat the client's back and buttocks with baby powder after bathing. c. Use a turn sheet lifted by two staff members to move the client in bed. d. Dust the linens with cornstarch each morning to allow for easier movement.

The parents of a toddler are concerned that the child is messy during eating and feed the child instead. What should the nurse respond to the parents? a. "That's probably best. I'm sure it makes your mealtime more pleasant." b. "At least you're sharing meals as a family. That's the most important." c. "Motor skills keep improving with age. Try not to get frustrated with the mess." d. "Your child will never learn if you don't let him experience."

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? a. Client fell out of bed but did push the call button for assistance. b. Client became tangled in the bed linens, then called for assistance after falling out of bed. c. Recorder responded to client's call light, upon entering the room, found client on floor. d. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

While waiting for the physician to respond regarding a client's elevated temperature, what can the nurse do to assist the client? a. Bathe the client with ice water. b. Give the client an antipyretic. c. Increase fluid intake. d. Lower the room temperature.

client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? a. Risk nursing diagnosis b. Syndrome diagnosis c. Wellness diagnosis d. Actual diagnosis

The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this client's risk for injury? (Select all that apply.) a. Cognitive awareness b. Mobility c. Nursing history d. Physical examination e. Marital status

c,d

The nurse suspects that an adolescent is working through the stages of spiritual development. What observations did the nurse make to come to this conclusion? (Select all that apply.) a. Imitated behavior demonstrated by parents b. Conceptualized angels and devils with the use of imagination c. Compartmentalized differences between spiritual beliefs with friends d. Determined differences between spiritual beliefs as being right or wrong e. Met with the church priest to talk about the differences in spiritual beliefs

c,d,e

A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client? (Select all that apply.) a. Shower b. Tub bath c. Self-help bed bath d. Therapeutic bath e. Partial bath

c,e

) A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the client's medications? a. Nothing, as the medications all need to be reordered at the long-term care facility. b. Have the client's medication prescriptions filled before going to the long-term care facility. c. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. d. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

11) Assistive personnel are caring for a client's ears. What information should be reported to the nurse? a. Excessive earwax b. Loud talking c. Presence of a hearing aid d. Presence of any drainage

17) A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower. The nurse identifies which factor as influencing this client's hygienic practice? a. Religion b. Personal preference c. Culture d. Health and energy

5) The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper handwashing technique with this client? a. Allow the water to splatter forcibly when it is turned on. b. Clean the faucet after use. c. Hold the hands upward under the faucet. d. Use approximately a teaspoon of soap.

6) A client is being seen in the mental health clinic for antisocial behavior. According to Erikson's stages of development, the nurse realizes that this client is experiencing which task of development? a. Initiative versus guilt b. Industry versus inferiority c. Intimacy versus isolation d. Identity versus role confusion

6) The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the nurse use to make this decision? a. A forceful radial pulse is much too difficult to count correctly. b. Both arteriole and venous sounds were heard simultaneously. c. The pulse was bounding and easily obliterated. d. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

A client reports following the "food pyramid" to guide nutritional intake. How should the nurse evaluate this information? a. Because this food pyramid is produced by the U.S. Department of Agriculture, the client is likely consuming necessary levels of all essential nutrients. b. The food pyramid is most useful when applied to the nutritional intake of children. c. The food pyramid is not very useful because it does not take fluid intake and combination foods into consideration. d. The food pyramid has been replaced with MyPlate to be used as a guide for dietary intake.

A community health nurse is planning adult health education classes. According to Erikson's stages of development, the nurse should address which task with this age group? a. Industry versus inferiority b. Identity versus role confusion c. Intimacy versus isolation d. Generativity versus stagnation

After ambulating a client to the bathroom, the assistive personnel did not reattach the client's bed safety-monitoring device, and the client fell out of bed. What should the nurse document? a. Client fell out of bed; bed safety-monitoring device malfunctioning. b. Client fell out of bed; client removed leg band of bed safety-monitoring device. c. Client fell out of bed; no observable injuries. d. Client fell out of bed; bed safety-monitoring device not activated.

An older client has an oral temperature reading of 97.2°F. The nurse realizes that this client's low temperature could be due to which observation? a. The anxiety level of the client has increased. b. Hormones have fluctuated in this client. c. Muscle activity has increased during the client's therapy session. d. Loss of subcutaneous fat is noted.

As the nurse is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? a. Allow the client to take some extra deep breaths. b. Continue to suction but only intermittently. c. Keep the catheter in place and wait a few minutes. d. Stop suctioning and give supplemental oxygen.

Assistive personnel are assigned the task of feeding breakfast to older clients with alterations in mobility and orientation. What instruction should the nurse include in this delegation? a. Breakfast should be completed quickly so that baths may begin. b. Give fluids before and after each bite of solid foods. c. Stand to the left of right-handed clients during feeding. d. Engage the client in conversation during the meal.

Before providing care, the nurse reviews the client's pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? a. The client's medical record b. The MAR (medication administration record) c. The written care plan d. The Kardex

During a home visit, the nurse notes that a client with heart failure does not have a scale to measure daily weights. Which action should the nurse take when prioritizing this intervention? a. Buy the client a scale b. Identify this action as low priority c. Suggest that the client be hospitalized d. Identify a resource where a scale can be obtained

The client has a body mass index (BMI) of 30. How should the nurse interpret this finding? a. The client is underweight b. The client is malnourished c. The client is normal d. The client is overweight

The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation? a. Technical b. Interpersonal c. Creativity d. Cognitive

The nurse explains that development is based on in-born timetables and a child will be most likely able to meet this milestone at a specific time. Which theory is the nurse explaining? a. Havighurst's theory b. Task theory c. Psychosocial theory d. Maturational theory

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? a.Formulate a diagnosis. b. Verify the data. c. Research collaborative and nursing-related interventions. d. Identify the client's problem, health risks, and strengths.

The nurse is addressing the developmental needs of grade school students according to Erikson's theory of industry versus inferiority. Which activities should the nurse suggest? a. Providing time for running and playing sports, such as basketball, to increase gross motor skills b. Allowing "pretend" time during their classes, such as for dress-up or role-playing activities c. Presenting diversity in culture and practices as part of classroom study d. Helping them develop skills needed in the adult world, such as allowance budgeting

The nurse is assessing a client's risk for injury. Which finding should the nurse categorize as a lifestyle factor? a. Language barrier b. Chronic insomnia c. Diminished balance d. Access to illicit drugs

The nurse is bathing a client with Alzheimer disease. Which should the nurse remember to do during this bath? a. Help the client into a bathtub b. Place the client in the shower c. Complete the bath as quickly as possible d. Keep the body covered and wash one area at a time

The nurse is completing a spiritual assessment with an adult client. In which stage of Fowler's theory of development should the nurse expect for this client? a. Mythic-lyrical b. Intuitive-projective c. Universalizing d. Individuating-reflexive

The nurse is preparing to leave a client's isolation room. Which action should the nurse take first when removing a grossly soiled gown? a. Grasp the sleeve of the dominant arm and remove it with a gloved hand. b. Release the neck ties of the gown and allow the gown to fall forward. c. Untie the strings at the neck first. d. Untie the strings at the waist first.

The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as the reason for a daily bath? a. Assess skin integrity b. Develop a nurse-client relationship c. Moisturize the skin d. Stimulate circulation

The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client's body from microorganisms? a. Heavy smoking b. Moisturizing the skin c. Breakdown of skin d. Voiding quantity sufficient

The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? a. A client in the emergency department with abdominal pain b. A 19-year-old woman in her first trimester of pregnancy c. A 72-year-old male client with COPD d. An 86-year-old female client on steroid therapy

The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? a. Assessment is done at the beginning of the process. b. Evaluation is completed at the end of the process. c. They are the same and there is no need to differentiate. d. The difference is in how the data are used.

The nurse is surprised to learn that a client has a hearing deficit. Which type of hearing aid should the nurse suspect the client is using? a. In-the-ear b. In-the-canal c. Behind-the-ear d. Completely-in-the-canal

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? a. Administering parenteral medications b. Changing a dressing c. Performing a urinary catheterization d. Using personal protective equipment

The nurse observes a child ask a parent a "why" question about a social issue. For which age should the nurse plan teaching for the parent? a. Toddler b. School-age c. Adolescent d. Preschool-age

The nurse plans to provide foot care to a client. Which action should be taken to ensure for the client's safety? a. Cut off any calluses b. Soak the feet for 30 minutes c. Apply lotion between the toes d. Use water at 106-110°F

The school nurse is implementing a program to promote psychosocial development among adolescent teens at a high school. Which activity should the nurse include? a. Career planning b. Establishing peer groups c. Playing musical instruments d. Determining a value system

Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform? a. Implementing nursing intervention b. Determining the nurse's need for assistance c. Supervising delegated care d. Reassessing the client

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2-3 seconds of capillary refilling time. How would the nurse explain these findings? a. A change in the client's health status has occurred. b. The client has thrown a blood clot in that extremity. c. The RN's watch has stopped working. d. Too much pressure was applied over the pulse site.

nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation? a. A STAT order b. A one-time order c. A prn order d. standing order

The nurse is preparing to insert a nasogastric tube into a client. In what order will the nurse conduct the following steps? a. Ask the client to tilt the head forward. b. Insert the tube with its natural curve toward the client. c. Ask the client to hyperextend the neck. d. Have the client swallow a small amount of liquid. e. Employ a slight twisting motion on the tube.

d,a,b,e,c

The nurse is preparing to apply a moist aquathermia pack to a client's left upper leg. In which order should the nurse prepare and apply this treatment? a. Use tape or gauze ties to hold the pad in place. b. Set the desired temperature according to the manufacturer's instructions. c. Apply the pad to the body part. The treatment is usually continued for 30 minutes. d. Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer. e. Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use.

d,b,e,c,a

The nurse is preparing to irrigate a client's abdominal wound. In which order should the nurse perform this irrigation? a. Dry the area around the wound. b. Insert the catheter into the wound until resistance is met. c. Remove and discard clean gloves. d. Apply clean gloves. e. Irrigate until the solution flows clear. f. Select a syringe with a catheter attached or with an irrigating tip.

d,f,b,e,a,c

A client's nasogastric tube has been discontinued and needs to be removed. Place in order the steps the nurse will perform to remove this tube. a. Place the tube in a plastic bag. b. Ask the client to take a deep breath and to hold it. c. Smoothly withdraw the tube. d. Pinch the tube with the gloved hand. e. Observe the intactness of the tube. f. Apply clean gloves.

e,b,d,c,f,a

The nurse needs to apply personal protective equipment before entering a client's room. In which order should the nurse perform the following actions? Place the steps in the order in which they should be performed. a. Apply gloves. b. Apply eyewear. c. Apply the gown. d. Apply the face mask. e. Perform hand hygiene.

e,c,d,b,a

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