practice questions

The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should a) Be aware that confused clients do not feel as much pain due to their confusion .b) Observe the client carefully for changes in behavior or vital signs. c) Ask the client's family how much pain the client normally has. d) Use only pain scales that feature numbers or "faces" the client can point to.

.b) Observe the client carefully for changes in behavior or vital signs.

When using ice massage for pain relief, which of the following are correct? (Select all that apply.) 1 Apply ice using firm pressure over skin. 2 Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. 3 Apply ice until numbness occurs and discontinue application. 4 Apply ice for no longer than 10 minutes.

1 Apply ice using firm pressure over skin. 2 Apply ice until numbness occurs and remove the ice for 5 to 10 minutes.

A postoperative patient is currently asleep. Therefore the nurse knows that: 1 The sedative administered may have helped him sleep, but assessment of pain is still needed. 2 The intravenous (IV) pain medication is effectively relieving his pain. 3 Pain assessment is not necessary. 4 The patient can be switched to the same amount of medication by the oral route.

1 The sedative administered may have helped him sleep, but assessment of pain is still needed.

identify 2 nursing activities carried out in the intimate distance zone:

1. peri care 2. bathing 3. catheter cares 4. assessment 5. toileting

Which of the following signs or symptoms in an opioid-naive patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1 Oxygen saturation of 95% 2 Difficulty arousing the patient 3 Respiratory rate of 10 breaths/min 4 Pain intensity rating of 5 on a scale of 0 to 10

2 Difficulty arousing the patient

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1 Stool softener 2 Stimulant laxative 3 H2 receptor blocker 4 Proton pump inhibitor

2 Stimulant laxative

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1 The patient's wife is the best resource for determining the level of pain since she has been with him continually for the entire day. 2 The patient's report of pain is the best method for assessing the pain. 3 The patient's health care provider has the best knowledge of the level of pain that the patient that should be experiencing. 4 The nurse is the most experienced at assessing pain.

2 The patient's report of pain is the best method for assessing the pain.

After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient's respiratory rate and depth are within normal limits. The nurse now plans to implement the following action: 1 Discontinue all ordered opioids 2 Close the room door to allow the patient to recover 3 Administer the remaining naloxone over 4 minutes 4 Assess patient's vital signs every 15 minutes for 2 hours

4 Assess patient's vital signs every 15 minutes for 2 hours

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1 Addiction. 2 Tolerance. 3 Pseudoaddiction. 4 Physical dependence.

4 Physical dependence.

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (select all that apply) A. inspect the feet daily B. use moisturizing lotion on the fee tC. wash the feet with warm water and let them air dry D. use over-the-counter products to treat abrasions E. wear cotton socks

A, B, E

A nurse is beginning a completed bed bath for a client. After removing the client's gown and placing a bath blanket of the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. Face

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care B. Discontinue morning care for 2 days C. Preform all care as quickly as possible D. ask a family member to come in to bathe the client

A. Schedule rest periods during morning care

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. turn the client's head to the side B. place two fingers in the client's mouth to open it C. brush the client's teeth once per day D. inject a mouth rinse into the center of the client's mouth

A. turn the client's head to the side

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (select all that apply) A. cut nails frequently B. assess skin for redness, abrasions, and open areas daily C. soak feet in water at least 10 minutes before nail care D. apply lotion to feet daily E. Clean between toes after bathing

B, D, E

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. pull down and out at the back of the upper denture to remove B. brush the dentures with a toothbrush and denture cleaner C. rinse the dentures with hot water after cleaning D. place the dentures in a clean, dry storage container after cleaning them

B. brush the dentures with a toothbrush and denture cleaner

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (select all that apply) A. prone position B. sims' position C. semi-fowler's position with head to side D. Trendelenburg position E. supine position

B. sims' position C. semi-fowler's position with head to side

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?

Determine the clients ability to help with transfer

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?

Have a table beside your bed so you can sit on the bedside and rest your arms on the table.

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? Supine Semi-fowlers Semi-prone Trendelenburg

Semi-fowlers

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching?

The lower my center of gravity, the more stability I have to broaden my base of support, I should spread my feet apart When I lift an object, I should hold it as close to my body as possible

a nurse is using SBAR to discuss her patient's situation, which statement is consistent with the R from the nurse to MD? a. I believe the patient may have internal bleeding on, would you like me to order a hemoglobin? b. the patient is very confused and agitated. c. the patient is admitted with abdominal pain and has a history of diverticulus. d. the heart rate is 110, the blood pressure is 100/56, temp is 100, and RR is 22

a. I believe the patient may have internal bleeding on, would you like me to order a hemoglobin?

Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse? a) "If you take more morphine, it will not change your pain relief." b) "I'll call the physician and ask for an increased dose." c) "The amount you are taking now is all I can give you." d) "I'm worried if we increase your dose that you will stop breathing."

b) "I'll call the physician and ask for an increased dose."

while admitting a patient, during the initial interview, a family member tells you, "My mom really means that she does not understand her medical diagnosis." the communication form used by the family member is: a. focusing b. clarifying c. summarizing d. paraphrasing

b. clarifying

nonverbal communication includes: a. environment, referent, channels, messages b. personal appearance, posture and gait, facial expression, eye contact, sounds and personal space c. denotative and connotative meaning, pacing, intonation, vocabulary

b. personal appearance, posture and gait, facial expression, eye contact, sounds and personal space

It is most important for the nurse to understand the various ways in which pain is classified a) So that he or she can document the client's pain using accurate terms b) So that he or she can be clear in communication with the physician c) So that he or she can develop an effective pain management plan d) So that he or she can educate the client thoroughly

c) So that he or she can develop an effective pain management plan

a patient is recurring to the nursing unit after knee surgery is verbalizing pain at the surgical site. the nurse's first action is to: call the patients health care provider administer pain medication as ordered check the patients vital signs assess the characteristics of the pain

call the patients health care provider assess the characteristics of the pain ??

you are caring for a patient who is hearing impaired which intervention do you use? shout at patient turn the TV volume up get the patient's attention before speaking take off their glasses

get the patient's attention before speaking

Which nonpharmacologic pain management intervention techniques encourages relaxation through visualization? breath work music guided imagery massage

guided imagery

which one of the following instructions is crucial for the nurse to give both family members and the patient who is about to be started on a PCA of morphine? only the patient should push the button do not use PCA until the pain is severe the PCA prevents overdoses from occuring notify the nurse when the button is pushed

only the patient should push the button

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include?

request assistance when repositioning a client Avoid twisting your spine or bending at the waist Use smooth movements when lifting and moving clients

identify 4 types of challenging communication

type of patient (annoyed, aggravated, flirtatious, silent)