UPDATED Exam 3 Yoost

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make?

"The penlight will allow me to look at the pulses in your neck."

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (Select all that apply.)

- Auscultate the apical pulse - Ask the client if they experience shortness of breath - check the color of the clients skin - inspect the extremities for the presence of edema

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (Select all that apply.)

- Full, bounding pulse noted bilaterally in the carotid arteries upon palpation is correct. - Distention of the jugular vein on one side of the neck is correct. -The left carotid artery pulse is weak is correct

A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (Select all that apply.)

-"I am going to start walking several times a week." -"I plan to join a support group to help me stop smoking." -"I will be sure to have my blood pressure checked at least every year."

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (Select all that apply.)

-Instruct the client to sit with their legs uncrossed. - Encourage the client to avoid tobacco products. - Instruct the client to cleanse the area with mild soap - Instruct the client to wear shoes when ambulating

A nurse is auscultating a client's heart sounds. Place the nursing actions for auscultation of the heart in the correct order. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. Elevate the head of the bed 30° and instruct the client to breath normally is the first step. 2. Visualize the anatomy of the heart is the second step. 3. Place the stethoscope to the right sternal border at the second intercostal space is the third step. 4. Place the stethoscope close to the sternal border at the fourth intercostal space is the fourth step. 5. Auscultate the apical pulse for 1 min is the fifth step.

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report?

A forceful chest movement at the midclavicular line in the fourth intercostal space

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation?

An adolescent who has an s3 heart sound

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?

Capillary refill of 3 seconds

A nurse is auscultating heart sounds. Identify the location where the apical pulse is auscultated

D

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress?

Discuss the benefits of meditation with the client

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?

Have the client lay supine with the head of the bed at a 45° angle.

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include?

Limit sodium intake to less than 3,000 mg/day.

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease?

Palpable dorsalis pedal pulse

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease?

Sibling who has hypertension

which intrinsic factors would be of major concern to the nurse when the community has an outbreak of pertussis? select all that apply. a. age b. gender c. ethnic group d. cultural background e. immunization status

a. age e. immunization status

which actions describe the primary scope of practice of a public health nurse? select all that apply. a. assesses populations within the community b. emphasizes health promotion and disease prevention using evidence-based strategies c. focuses on individual setting-specific care d. collaborates with community stakeholders to ensure that essential health services are available to the community e. promotes health policies to protect health

a. assesses populations within the community b. emphasizes health promotion and disease d. collaborates with community stakeholders to ensure that essential health services are available to the community e. promotes health policies to protect health

a registered nurse delgates a bed bath to an unlicensed assistive personnel. after lunch, the patient rings for the nurse and complains that he has not yet been cleaned up. he is very upset and angry. what should the nurse's next action be? a. assist the patient in getting cleaned up b. write up the UAP for not carrying out the assignment c. report the UAP to the unit manager d. go find the UAP, and tell her to complete the bed bath immediately

a. assist the patient in getting cleaned up

when the nurse is establishing goals for a community health initiative, which strategy is most important to incorporate in the planning process? a. collaboration with key stakeholders b. help from professional interpreters c. location of schools and businesses d. gender of primary care providers

a. collaboration with key stakeholders

what is the best method for the public health nurse to determine whether community members are involved in outdoor physical activity? a. meet the parents of high school children b. complete a windshield survey of the community c. evaluate the number of commuity health club members d. check the local health statistics for the incidence of obesity

a. meet the parents of high school children

after analyzing patient data, the RN on an inpatient medical unit delegates vital signs and morning are to the UAP for five stable patients. the nurse asks the UAP to document the vital signs, and report any abnormal results immediately. which rights of delegation is the nurse demonstrating? select all that apply. a. right person b. right circumstance c. right time d. right supervision e. right patient

a. right person b. right circumstance d. right supervision

which statement is an example of the use of situational leadership? a. the emergency department manager takes a vote on holiday coverage and then responds to a code blue by directing orders at the nursing staff b. the manager in surgery uses the vacation policy to grant time off and then performs a surgical count in an operating room by using a checklist c. a vice president of nursing allows the department directors to make a deciison about a hospital policy on holiday time and then sides with a nurse who does not want to work the required time d. the CEO of the hospital instructs the nursing senate to develop a dress code and then changes the dress code after determining he does not like it

a. the emergency department manager takes a vote on holiday coverage and then responds to a code blue by directing orders at the nursing staff

a nurse manager is trying to improve patient satisfaction ratings for her area of responsibility. the manager meets with the staff and forms an ad hoc committee to address the issues around the problem. this is an example of what style of leadership? a. bureaucratic b. democratic c. laissez-faire d. autocratic

b. democratic

which action would be most appropriate for the home care nurse to take if an intrinsic factor appears to be contributing to a client's illness? a. report the presence of multiple insects in the home to the health department b. document the intrinsic factor in the client's electronic health record c. explore the possible impact of changing jobs for stress reduction d. discuss the danger of having multiple throw rugs with the client

b. document the intrinsic factor in the client's electronic health record

a client with metastatic cancer shares with the clinic nurse that he has only days or weeks to live. what type of community service would be most appropriate for the nurse to suggest to this client? a. home health care b. hospice care c. forensic care d. acute care

b. hospice care

a nurse is volunteering in the community to educate parents to increase the number of children in the school district who are immunized. the nurse oversees the activities of a group of volunteers. which role best describes the nurse's activity in this situation? a. management b. leadership c. volunteerism d. activism

b. leadership

which intervention should the college health clinic nurse implement as a secondary prevention strategy to identify students at risk for diabetes? a. nutrition education on high-protein food availablity b. promotion of registration in fitness classes c. blood glucose screening at the health fair d. administration of prescribed insulin

c. blood glucose screening at the health fair

a nurse states that she believes in the dignity of each patient. at break, she is overheard talking about a patient in a persistent vegetative state as a "lump". this represents an inconsistency in which quality of an effective leader? a. dedication b. magnanimity c. integrity d. humility

c. integrity

which statement most closely reflects the differences between nurse leaders and managers? a. nurse leaders are always in formal positions of authority b. nurse managers use transactional principles to accomplish goals c. nurse leaders rely primarily on interpersonal skills to accomplish goals d. nurse managers rely on supervisors for accountability and responsibility

c. nurse leaders rely primarily on interpersonal skills to accomplish goals

processes used in management parallel the nursing process. which sentence describes a nurse using a management principle paralleled with the nursing process? a. planning is demonstrated when the nurse motivates others b. directing is demonstrated when the nurse plans care for the patient c. organizing is demonstrated when the nurse coordinates care for patients d. controlling is demonstrated when the nurse tells other staff members what to do

c. organizing is demonstrated when the nurse coordinates care for patients

when developing treatment plans, which assumption should the nurse consistently make about individual clients within vulnerable populations? a. educational levels are minimal b. economic resources are strong c. personal beliefs are important d. support systems are extensive

c. personal beliefs are important

the nurse manager is monitoring overtime for the unit. she closely monitors staff hours and does not allow staff to come in for extra hours if they are over their allotted time per week. this is an example of which of Mintzberg's decisional roles of the manager? a. entrepreneur b. disturbance handler c. negotiator d. resource handler

d. resource handler

the outpatient clinic nurse develops a plan of care focusing on diet, exercise, and glucose monitoring for a preteen recently diagnosed with early-onset type 2 diabetes. on what type of interventions has the nurse based on the client's care plan? a. primary b. proactive c. secondary d. tertiary

d. tertiary

to be effective, nurse managers should focus on which area? a. cost-effective operation of the unit b. motivation of the staff c. accomplishing organizational goals d. the patients and their needs

d. the patients and their needs