review 101

A client is being seen in the clinic due to insomnia that has been increasing in severity and frequency in recent months. What questions would the nurse include in an assessment of this client's health problem? Select all that apply.

"Do you smoke?" "What medications are you currently taking?" "What is your routine for preparing for bed?" "How would you state your mood is lately?"

The nurse is providing primary prevention education to a group of clients. What actions by the nurse would indicate primary prevention activities? Select all that apply.

-Counseling a client about smoking cessation and making a plan -Teaching clients about a healthy nutritional plan

A recently licensed registered nurse is preparing to enter practice in an acute care facility and wants to practice within the guidelines of that state. When preparing to research the state nurse practice act, what information is important to obtain? Select all that apply.

-Definition of legal scope of nursing practice -Definition of important terms related to nursing -Establishment of educational criteria

The nurse is performing vital signs for several clients. When assessing body temperature, what should the nurse take into consideration? Select all that apply.

An oral temperature may be taken if the client has oxygen by nasal cannula. Tympanic temperature readings closely reflect core body temperature. Temporal artery thermometer readings may be affected by perspiration or air blowing over

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition?

Client reports feeling dizzy when sitting up from a supine position. Client reports feeling palpitations when rising from a supine to a standing position. The client states, "I feel lightheaded when sitting up."

Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply.

Collecting additional client data Modifying the client plan of care

The nurse assigned to care for a client who has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions?

Confirming that the UAP has successfully passed this skill competency Being available for questions from the UAP Giving a report on the client to the UAP and answering questions Confirming that the UAP has repeatedly completed similar tasks

Which exercises would the nurse recommend when planning isometric exercise for a client? Select all that apply.

Contracting the quadriceps Kegel exercises Contracting and releasing the gluteal muscles

Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process

Nurses practice asepsis, which encompasses all activities to prevent infection. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection.

A nursing student is writing a care plan for an assigned client to be submitted to the instructor. Before submitting the care plan the student reviews it to ensure that all the necessary components have been addressed. Which component would the student look for?

Nursing diagnoses Client goals Outcome criteria Interventions with rationales Evaluation

A nurse is performing health promotion activities for clients at a local health care clinic. Which nursing actions exemplify the focus of secondary preventive care? Select all that apply.

Screening clients for hypertension Scheduling a mammogram for a client Referring a client to family counseling

The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply

To confirm previously collected data To reveal changes from previously collected data To help establish a diagnosis To monitor clients' responses to treatment

The nurse is perforrming an admission for a client determined to be a high fall risk. What interventions should be a priority for the nurse to employ to provide a safe environment for the client? Select all that apply.

Use a chair alarm when the client is out of the bed. Use a bed alarm to signal when the client gets up

Which outcome statements are in the cognitive realm?

Within 1 week after teaching, the client will list three benefits of quitting smoking. By 6/8/20, the client will describe a meal plan that is high in fiber. After viewing the film, the client will verbalize four benefits of daily exercise.

For which clients would the nurse be required to use droplet precautions?

a client with rubella a client with mumps a client with diphtheria prioritization

A client presents to the Emergency Department with a temperature of 100.6F (38.1°C) and BP of 108/60 mmHg. What intervention does the nurse anticipate providing?

oral fluids

The nurse has assessed a pulse deficit when taking the pulse of a client. What does this assessment indicate for the client?

the difference between apical and peripheral pulse rate The apical pulse is higher than the radial pulse. The health care provider should be notified of any increase in pulse deficit.