Prep U quiz 1 - SATA

The nurse is caring for a client whose cultural background is different than their own. Which nursing actions are appropriate? Select all that apply. Understand that all cultures experience pain in the same way Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. Respect the client's cultural beliefs through word and actions. Explain the nurses beliefs so the client will understand the differences Ask the client if there are cultural or religious requirements that should be considered in the plan of care.

Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. Respect the client's cultural beliefs through word and actions. Ask the client if there are cultural or religious requirements that should be considered in the plan of care.

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client's rash? Select all that apply. "When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "How old are you?" "What have you been using to treat the rash?" "Have you recently traveled outside the country?" "Do you smoke cigarettes or drink alcohol?"

• "When did the rash start?" • "Are you allergic to any medications, foods, or pollen?" • "What have you been using to treat the rash?" • "Have you recently traveled outside the country?"

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply. Wear sterile gloves to change the fluids Call the health care provider (HCP) for a temperature above 100° F (37.8° C). Place the IV bag on a table level with the client's arm Cleanse the port with alcohol wipes. Report signs of redness or inflammation at the site.

• Call the health care provider (HCP) for a temperature above 100° F (37.8° C). • Cleanse the port with alcohol wipes. • Report signs of redness or inflammation at the site.

A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply. Edema Skin pink in color Strong, bounding pulses Normal sensation Skin discoloration Skin temperature changes

• Edema • Skin discoloration • Skin temperature changes

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. Encourage the client to cough to expectorate secretions. Elevate the head of the bed 15 to 20 degrees. Contact the health care provider (HCP) if ICP is greater than 15 mm Hg. Monitor neurologic status using the Glasgow Coma Scale. Stimulate the client with active range-of-motion exercises.

• Elevate the head of the bed 15 to 20 degrees. • Contact the health care provider (HCP) if ICP is greater than 15 mm Hg. • Monitor neurologic status using the Glasgow Coma Scale.

The nurse is developing a care plan for a client who has leukemia. What instructions should the nurse include in the plan? Select all that apply. Monitor temperature and report elevation. Recognize signs and symptoms of infection. Avoid crowds. Maintain integrity of skin and mucous membranes. Take a baby aspirin each day.

• Monitor temperature and report elevation. • Recognize signs and symptoms of infection. • Avoid crowds. • Maintain integrity of skin and mucous membranes.

A nurse is teaching a client about taking antihistamines. Which information should the nurse include in the teaching plan? Select all that apply. Operating machinery and driving may be dangerous while taking antihistamines. Continue taking antihistamines even if nasal infection develops. The effect of antihistamines is not felt until a day later. Do not use alcohol with antihistamines. Increase fluid intake to 2,000 mL/day.

• Operating machinery and driving may be dangerous while taking antihistamines. • Do not use alcohol with antihistamines. • Increase fluid intake to 2,000 mL/day.

When communicating with a client who has aphasia, which approaches are helpful? Select all that apply. Present one thought at a time. Avoid writing messages. Speak with normal volume. Make use of gestures. Encourage pointing to the needed object.

• Present one thought at a time. • Speak with normal volume. • Make use of gestures. • Encourage pointing to the needed object.

What should the nurse do to prevent catheter associated urinary tract infection (CAUTI)? Select all that apply. Change the catheter daily. Provide perineal care several times a day. Monitor the temperature as an indicator of the infection. Encourage the client to drink 3,000 mL of fluids a day. Recommend the health care provider (HCP) prescribe antibiotics.

• Provide perineal care several times a day. • Monitor the temperature as an indicator of the infection. • Encourage the client to drink 3,000 mL of fluids a day.

Which activities should the nurse encourage the unlicensed assistive personnel (UAP) to assist with in the care of postoperative clients? Select all that apply. Teach client proper use of the incentive spirometer Reposition clients for pain relief. Empty and measure indwelling urinary catheter collection bags. Assess IV insertion site for redness Tell the nurse if clients report they are having pain.

• Reposition clients for pain relief. • Empty and measure indwelling urinary catheter collection bags. • Tell the nurse if clients report they are having pain.

A client has a tumor of the posterior pituitary gland. The nurse planning his care would include which interventions? Select all that apply. Take daily weight. Restrict fluids. Assess urine specific gravity. Encourage intake of coffee or tea. Monitor intake and output.

• Take daily weight. • Assess urine specific gravity. • Monitor intake and output.

Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. Assessing a client's pain Taking a client's vital signs Documenting a client's oral intake Performing a blood glucose check Evaluating a client's response to a blood pressure medication

• Taking a client's vital signs • Documenting a client's oral intake • Performing a blood glucose check

The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel. The nurse should develop a teaching plan that includes which points? Select all that apply. The client should report unexpected bleeding or bleeding that lasts a long time. The client should take clopidogrel with food. The client may bruise more easily and may experience bleeding gums. Clopidogrel works by preventing platelets from sticking together and forming a clot. The client should drink a glass of water after taking clopidogrel.

• The client should report unexpected bleeding or bleeding that lasts a long time. • The client may bruise more easily and may experience bleeding gums. • Clopidogrel works by preventing platelets from sticking together and forming a clot

An elderly client hospitalized 4 days ago for treatment of acute respiratory distress has become confused and disoriented. The client has been picking invisible items off blankets and has been yelling at the daughter who is not in the room. The family tells the nurse that the client has been treated for anxiety with alprazolam for years, but alprazolam is not on the current medication list. Which safety measures should be implemented? Select all that apply. The client will be placed on withdrawal precautions and treatment started immediately. The client will be placed in soft restraints. A prescription should be obtained to help with the hallucinations. The daughter should not visit until the client is better. The client's medical and mental status will be evaluated frequently and treated as needed.

• The client will be placed on withdrawal precautions and treatment started immediately. • A prescription should be obtained to help with the hallucinations. • The client's medical and mental status will be evaluated frequently and treated as needed.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply. The nurse was correct to call a code blue. The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. She must have read the chart incorrectly. The code should have continued.

• The physician was correct to stop resuscitation efforts. • By calling a code blue, the nurse disregarded the client's advance directives and DNR order.

A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness of breath. The health care provider (HCP) has prescribed 2 units of packed red blood cells (RBCs). What should the nurse determine prior to initiating the blood transfusion? Select all that apply. There is an IV access with the appropriate tubing and normal saline as the priming solution. There is a signed informed consent for transfusion therapy. Blood typing and cross-matching are documented in the medical record. The vital signs have been taken and documented in accordance with facility policy and procedure. There is the second unit of blood in the medication room. The client has an identification bracelet.

• There is an IV access with the appropriate tubing and normal saline as the priming solution. • There is a signed informed consent for transfusion therapy. • Blood typing and cross-matching are documented in the medical record. • The vital signs have been taken and documented in accordance with facility policy and procedure. • The client has an identification bracelet.

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that her significant other is the only family member who knows her health status. What should the nurse do to keep the client's health status confidential? Select all that apply. Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client. Discuss the case with the client's mother, who is an immediate family member. Discuss the case at lunch to educate other staff members. Keep a unit log of all clients infected with HIV for research purposes.

• Use the hospital code for HIV when documenting care. • Ask all family members, except the client's significant other, to wait outside when she's educating the client.

A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply. Administer the cefazolin. Verify the medication order as written by the by the health care provider. (HCP). Contact the pharmacy and speak to a pharmacist. Request that cephalexin be sent promptly. Return the cefazolin to the pharmacy.

• Verify the medication order as written by the by the health care provider. (HCP). • Contact the pharmacy and speak to a pharmacist. • Request that cephalexin be sent promptly. • Return the cefazolin to the pharmacy.

The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give "hand-off reports" at which times? Select all that apply. change of shift change of nurses when the nurse goes to lunch when the unit clerk goes to a staff meeting when new medication prescriptions are written

• change of shift • change of nurses • when the nurse goes to lunch

A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife: Select all that apply. gives her husband a long-acting or sustained-release oral pain medication regularly around the clock. uses an immediate-release medication (oxycodone) for breakthrough pain. avoids long-acting opioids due to her concern about addiction. uses music for distraction as well as heat or cold in combination with medications. substitutes acetaminophen to avoid tolerance to the medications. has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal.

• gives her husband a long-acting or sustained-release oral pain medication regularly around the clock. • uses an immediate-release medication (oxycodone) for breakthrough pain. • uses music for distraction as well as heat or cold in combination with medications. • has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal.

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Check all that apply. maintaining an upright position while eating restricting the diet to liquids until swallowing improves introducing foods on the unaffected side of the mouth keeping distractions to a minimum cutting food into large pieces of finger food

• maintaining an upright position while eating • introducing foods on the unaffected side of the mouth • keeping distractions to a minimum

A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.) nail bed color fluid intake skin temperature nausea pain in extremity

• nail bed color • skin temperature • pain in extremity

The client is admitted to the hospital for alcohol detoxification. Which intervention should the nurse use? Select all that apply. taking vital signs monitoring intake and output placing the client in restraints as a safety measure reinforcing reality if the client is disoriented or hallucinating explaining to the client that the symptoms of withdrawal are temporary

• taking vital signs • monitoring intake and output • reinforcing reality if the client is disoriented or hallucinating • explaining to the client that the symptoms of withdrawal are temporary

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply. that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications that the client's relative, spouse or legal guardian was present

• that there was adequate disclosure of information • that the client understood the information • that there was voluntary consent on the client's part • that the client has full awareness of the potential complications

A 77-year-old client is brought to the emergency department by her son. The client has a severe headache and lack of sleep because "I am so worried about everything." Her son says that she has heart failure and chronic schizophrenia. "In addition to all of her heart medicines, she is on aripiprazole, which was increased to 30 mg by her health care provider (HCP) 3 days ago." In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which factors? Select all that apply. the qualifications of the client's HCP the client's symptoms of schizophrenia the dose of aripiprazole the client's symptoms of heart failure the client's relationship with her son

• the client's symptoms of schizophrenia • the dose of aripiprazole • the client's symptoms of heart failure

A client is taking diazepam while establishing a therapeutic dose of antidepressants for generalized anxiety disorder. Which instruction should the nurse give to this client? Select all that apply. to consult with his health care provider (HCP) before he stops taking the drug to avoid eating cheese and other tyramine-rich foods to take the medication on an empty stomach not to use alcohol while taking the drug to stop taking the drug if he experiences swelling of the lips and face and difficulty breathing

• to consult with his health care provider (HCP) before he stops taking the drug • not to use alcohol while taking the drug • to stop taking the drug if he experiences swelling of the lips and face and difficulty breathing

A female client with which condition would be at risk for increased severity of vulvovaginal candidiasis? Select all that apply. uncontrolled diabetes immunosuppression due to cancer human immunodeficiency virus (HIV) infection hypertension asthma

• uncontrolled diabetes • immunosuppression due to cancer • human immunodeficiency virus (HIV) infection

A 14-year-old with rheumatic fever who is on bed rest is receiving an IV infusion of dextrose 5% r administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply. when the infusion is started at the beginning of each shift when the child returns from X-ray when the child moves in the bed when the child is sleeping

• when the infusion is started • at the beginning of each shift • when the child returns from X-ray