Week 1 pre assessment quiz

A nurse is reinforcing, teaching with a client who is obese, and has obstructive sleep apnea about how to decrease the number of apneic episodes. He has each night, which of the following statements should the nurse identify as an indication that the client understands the instructions.

"I am going to try to lose about 50 pounds" Rationale : weight loss, and maintaining an optimum weight help decrease the number of apneic episodes per night or completely eliminate them

A nurse is collecting data from a client about pitting Adema and notes and indentation of 6MM at the point of pressure which of the following numbers should the nurse document to indicate the intensity of the clients edema

3+ Rationale : the nurse should document pitting edema of 5 to 7MM as 3+

A nurse is collecting data about the fluid status of four clients, which of the following clients should the nurse identify as being at risk for fluid volume deficit

A client who has gastroenteritis and receiving oral fluids Rationale : gastroenteritis causes diarrhea and vomiting, so it can be a significant source of fluid loss. The nurse should identify this client as having risk for fluid volume deficit.

The family of a client who has died unexpectedly arrives immediately after the death, which of the following actions should the nurse take

Allow the family to view the body privately Rationale : The family members are the clients now their immediate needs include, confirming the death by viewing the body privacy is important at this time.

A nurse is caring for a client who had a severe traumatic brain injury three weeks ago, remains unconscious and is unlikely to recover while bathing the client. The assistive personnel talks to him about current events. The clients partner asked the nurse why the AP talks to the client which of the following responses should the nurse make

Although your partner is not responding to us, he might still be able to hear Rationale : hearing is one of the last senses to fade in clients who are unconscious. The nurse should encourage the partner and the staff to talk to him about neutral topics like the weather and benign current events to provide minimally stressful sensory stimulation.

An older adult client falls and fractures her hip while a nurse is assisting her to the bathroom. The client sues the nurse for negligence. The nurse should identify which of the following principles as the standard that will legally determine her liability for the clients injury.

Another staff nurse describes how a reasonably prudent nurse would have performed under the same circumstances Rationale : in court, the standard that determines negligence is how a reasonably prudent nurse, with the same education and experience would have performed under the same circumstances

A nurse is caring for a client who has a prescription for a stool quaiac test The client asked the nurse about the purpose of the test. The nurse should respond by stating the stool guaiac is testing for which of the following findings in the clients feces?

Blood Rationale : a guaiac Cicco occult blood test to text microscopic amounts of blood in the stool and is a screenings tool for colorectal cancer

A nurse is reviewing the medical record of a client who is scheduled for a surgical procedure. Click to highlight the findings in the medical record that require notifying the provider.

Blood pressure 148/98 Temperature 38.1°C (100°F) WBC count 12,600 /mm3 Client reports having a little cough and runny nose for the past three days Rationale : the nurse should identify that the clients blood pressure is above. The expected reference range increasing the clients risk for cardiovascular complications during the surgical procedure. Therefore, the nurse should report this finding to the provider. The nurse should identify that the clients temperature is above. The expected reference range, which can indicate an infection that increases the clients risk of surgical complications, including fluid and electrolyte imbalance. Therefore the nurse should report this finding to the provider. Nurse should identify that the client WBC count is above the expected reference range which indicates an infection. This increases the clients risk of surgical complications. Therefore the nurse should report this finding to the provider.

A nurse is unable to read a new prescription written by a provider. which of the following actions should the nurse take?

Contact the provider to clarify the written prescription Rationale : the safest protocol for the nurse to follow when transcribing a written prescription that is difficult to read, is to clarify the prescription with the provider who wrote the prescription

A nurse on a medical surgical unit is assisting with the admission of a client who has vision loss which of the following actions is the nurses priority?

Describe the environment to the client Rationale : the greatest risk to this client is injury from falling or colliding with objects in the environment. She cannot see therefore, the priority action is to describe the new environment in detail to the client.

A nurse is caring for an older adult client in a long-term care facility which of the following measures should the nurse take for us when assisting with planning the client care?

Determining the clients mobility Rationale : the greatest wrist to this client is injury from moving without assistance. If he has impaired mobility therefore, the priority action is to collect data about the clients mobility, and need for assistance with transferring and ambulating.

A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm which of the following action should the nurse perform first

Discontinue the existing IV infusion Rationale : the greatest wrist to this client is further injury from the IV infusion or catheter. Therefore the first action, the nurse should take, is to discontinue the infusion by stopping the fluid flow and removing the catheter. redness swelling, and warmed indicate phlebitis.

A nurse is preparing to document a client information in the electronic medical record, which of the following nursing statements, identifies the purpose of documentation

Documentation provides a communication tool for the healthcare team Rationale: nurses document to communicate client data to the healthcare team

A nurse is collecting data for a newly admitted client which of the following actions should the nurse take next

Documenting the clients allergies in the electronic medical record Rationale: The first action, the nurse should take using the nursing process is to collect data from the client and then document these findings within the electronic medical record. This will allow for continuity of care in the case that another nurse or provider needs to perform care for this client if information, such as current medication's past medical history, laboratory, test, allergies, and consent forms are missing from the documentation sound clinical decisions might not be made

A nurse is caring for a client who has type one diabetes mellitus select the three findings that require immediate follow up

Glucose at 11:30 Client report of shakiness Heart rate Rationale : the clients blood glucose at 11:30 is less than the expected reference range indicating hypoglycemia using the stable versus unstable framework. The nurse should give the client 15 G of carbohydrate such as six saltine crackers to increase the clients blood glucose. Shakiness and diaphoresis are manifestations of hypoglycemia. This is a priority finding for the nurse to respond to using the stable versus unstable framework for prioritization. The client heart rate is greater than the expected. Reference range tachycardia is a manifestation of hypoglycemia, and when applying the stable versus unstable framework, this would be a priority for the Nurse.

A nurse is assisting with the care of a client who has a tracheostomy drag words from the choices below to fill in each blank in the following sentence

Hypoxia Pneumonia Rationale: when recognizing cues, the nurse should identify that manifestations of hypoxia include decrease, oxygen, saturation, cyanosis, restlessness, anxiety tachycardia, and increase respiratory rate Manifestations of pneumonia include elevated temperature prudent pulmonary secretions, adventitious breath and areas of lung inflammation on chest x-ray.

A nurse is caring for a client who is receiving total parenteral nutrition via an infusion pump when collecting data about the client receiving this therapy which of the following factors should the nurse monitor

IV Insertion sight Rationale : it is essential that the nurse monitor the IV insertion site generally for a central Venous access device for TPN for signs of infection, regardless of the fluid delivery system

He charged Nurse in a long-term care facility will be implementing a new protocol to meet the joint commissions, national safety goal of preventing healthcare associated pressure ulcers when informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is a priority

Identify the clients at greatest risk for development of pressure ulcers A pressure ulcer is a breakdown in the skin that occurs due to constant pressure against the skin reducing blood flow during immobility the most common locations are over, bony prominences such as the heels, hips and the ankles the first action the nurse should take using the nursing process is to collect data from the clients about the wrist for developing pressure ulcers

A home health nurse is caring for a client who has emphysema and has difficulty with mobility. The client spends most of his day, and a reclining chair, which of the following psychological responses to prolonged immobility. Should the nurse expect.

Increase calcium excretion Rationale : prolonged immobility leads to the breakdown of bone tissue. This results increased calcium excretion.

A nurse is reinforcing teaching with a client about relationship development. The nurse should explain that according to Erickson establishing relationships with commitment is a primary task of which of the following stages of psychosocial development.

Intimacy versus isolation Rationale: during the stage young adults, 18 to 25 years develop commitments to others and to their careers

A nurse on a medical unit is carrying for a client who requires seizure precautions, which of the following interventions should the nurse contribute to the client plan of care

Keep the clients bed in the lowest position Rationale : keeping the clients bed in. The lowest position is an important way to protect the client from injuries due to falling out of bed keeping a mattress on the floor can also help with this.

A nurse is attending a social gathering when another guest suddenly coughs weekly once graphs her throat with her hands and cannot talk which which of the following actions should the nurse take

Performed the Heimlich maneuver on the guest Rationale : it is likely that the guest has choked on food. Immediate action is essential. The nurse should perform the Heimlich maneuver by delivering and abdominal thrust to force the food out through the guest mouth and reestablish a patent airway.

A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needlestick injuries which of the following actions should the nurse recommend

Place uncapped needles in a puncture-proof container after use. Rationale : the nurse should always dispose of uncap needles in a puncture proof and leak proof container

When planning a home discharge for a client who has quadriplegia the nurse suggest that the family might need respite care services when a family member asked how respite Care can help which of the following responses should the nurse make

Respite care allows the primary caregiver time away from day-to-day care responsibilities Rationale : a client who has quadriplegia requires support for many activities of daily living primary caregivers need time to meet their own personal needs as well. Respite care allows time away from their day-to-day care responsibilities for the client.

A nurse is discussing respite care with the caregiver of an older adult client. When the caregiver asked about the purpose of respite care program, the nurse should reply that it provides which of the following services.

Temporary care Rationale : the purpose of respite care is to give family members temporary relief from the stress of providing care for a family member respite care programs help make alternative arrangements, so caregivers have time off to attend to their own needs

A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female client, which of the following actions by the nurse, should prompt the charge nurse to intervene

The nurse separates the clients labia with her dominant hand Rationale : the non-dominant hand should be used to separate the labia in female client. The dominant hand is the hand that should handle the catheter itself during insertion, and then fill the balloon. If the nurse were to separate the labia with her dominant hand, it would be difficult to then insert the catheter in a sterile environment during urinary catheter insertion. One hand remains sterile at all times failure to do so could result in contamination during the insertion of urinary catheter.

A nurse has accidentally punctured his finger with a needle. He used to give an IM injection to a client which of the following actions should the nurse take

Wash the puncture site with soap and water Rationale: This action will help remove any surface contaminants from the wound

A nurse at an extended care facility is instructing a class of assistive personnel about the use of assistive devices during client ambulation. Which of the following instructions should the nurse include about assisting client who use a cane?

When the client moves, he should move the cane forward first Rationale : when the client moves, he should first move the cane forward about 30.5 CM (12 in)

A nurse is planning home care for a school age child who is awaiting discharge to home following an acute asthma attack, which of the following growth and development stages according to Erickson should the nurse consider in the planning

industry vs inferiority Rationale : school-age children, according to Ericksons development, stages of industry, versus Inferiority engage in task and activities that help them develop competence and preserverance

A nurse plans to leave her scheduled shift an hour early without permission and without notifying the charge nurse. The clients assigned to the nurse are in stable condition. The charge nurse should identify this behavior as which of the following legal torts?

negligence Rationale : the nurses conduct displays negligence, which is providing client care below, the standard of care and placing the client address for harm the nurse could face charges of client abandonment