Wellness Exam 2
An American nurse tries to speak with a Korean client who cannot understand the English language. To effectively communicate to a client with a different language, which of the following should the nurse implement? A. Have an interpreter to translate. B. Speak slowly. C. Speak loudly and closely to the client. D. Speak to the client and family together.
A
Critical thinking and the nursing process have which of the following in common? Both: A. Are important to use in nursing practice B. Use an ordered series of steps C. Are patient-specific processes D. Were developed specifically for nursing
A
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply). A. Respiratory rate is 22/min with even, unlabored respiration B. The client's partner states, "They said they hurt after walking about 10 minutes. C. The client's pain rating is 3 on a scale of 0 to 10. D. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp
A, D, E
A Chinese-American client experiencing cough with clear white phlegm, which is believed to be a yin disorder, is likely to treat it with: A. Foods considered being yin. B. Foods considered being yang. C. Aromatherapy. D. Touch therapy.
B
A client centered goal is a specific and measurable behavior or response that reflects a client's: A. Desire for specific health care interventions B. Highest possible level of wellness and independence in function. C. Physician's goal for the specific client. D. Response when compared to another client with a like problem.
B
As goals, outcomes, and interventions are developed, the nurse must: A. Be in charge of all care and planning for the client. B. Be aware of and committed to accepted standards of practice from nursing and other disciples. C. Not change the plan of care for the client. D. Be in control of all interventions for the client.
B
For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques? A. Palpation B. Auscultation C. Inspection D. Percussion A. D, B, A, C B. C, A, D, B C. B, C, D, A D. A, B, C, D
B
A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. Contact the hospital's spiritual services B. Ask what is making the client cry C. Ensure no visitors or staff enter the room for a short time period D. Turn on the television for a distraction
C
A nurse in a nutrition clinic is calculating body mass index (BMI) for several clients. The nurse should identify which of the following client BMIs as overweight? A. 24 B. 30 C. 27 D. 32
C
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: Select all that apply. A. A body systems model B. A head-to-toe framework C. Maslow's hierarchy of needs D. Gordon's functional health patterns
C, D
After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. A. Constipation B. Anticipated grieving C. Ineffective airway clearance D. Ineffective tissue perfusion.
C, D, A, B
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply). A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG) tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hours to reduce pressure injury risk
C, D, E
A clinic nurse is performing an admission assessment for an African-American client scheduled for an emergency appendectomy. Which of the following questions would be inappropriate for the nurse to ask for the initial evaluation? A. Do you have any allergy to medicines? B. When did the pain start? C. Do you have any difficulty breathing? D. How close is your family during these situations?
D
A clinic nurse is preparing to examine a Hispanic child who was brought by the mother for his first physical check-up. While assessing the child, the nurse would avoid doing which of the following? A. Weighing the client. B. Asking the mother questions about the child. C. Having an interpreter if necessary. D. Admiring the child.
D
A nurse is caring a Native American client who experiences emotional distress due to a family problem. In anticipating pharmacological treatment for the client, the nurse understands that they would most likely: A. Establish the trust of the health care provider first before accepting the treatment. B. Call a clergy to ask for the religious preference of the treatment. C. Manage the emotional distress on their own to avoid disgrace. D. Resort with the use of herbal medicines with healing properties.
D
Collaborative interventions are therapies that require: A. Physician and nurse interventions. B. Nurse and client interventions. C. Client and Physician intervention. D. Multiple health care professionals.
D
Which of the following is an example of appropriate behavior when conducting a client interview? A. Recording all the information on the agency-approved form during the interview B. Asking the client, "Why did you think it was necessary to seek health care at this time?" C. Using precise medical terminology when asking the client questions D. Sitting, facing the client in a chair at the client's bedside, using active listening
D
Which of the following statements about the nursing process is most accurate? A. The nursing process is a four-step procedure for identifying and resolving patient problems. B. Beginning in Florence Nightingale's days, nursing students learned and practiced the nursing process. C. Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of nursing. D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.
D
Which organization's standards require that all patients be assessed specifically for pain? A. American Nurses Association (ANA) B. State nurse practice acts C. National Council of State Boards of Nursing (NCSBN) D. The Joint Commission
D
Which statement is correct regarding the etiology of a nursing diagnosis? A. The problem is a medical diagnosis B. Only one etiology can be specified for each problem C. The etiology is too general to generate specific interventions D. Related factors are the cause of a patient's problem
D
Well formulated, client-centered goals should: A. Meet immediate client needs. B. Include preventative health care. C. Include rehabilitation needs. D. All of the above.
D
Which of the following clients has the lowest risk of diabetes mellitus and stroke? A. A 45-year-old African-American woman. B. A 35-year-old Native-American man. C. A 30-year-old Hispanic-American man. D. A 25-year-old Asian-American woman.
D
The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? A. A client who is ambulatory. B. A client, who has a fever, is diaphoretic and restless. C. A client scheduled for OT at 1300. D. A client who just had an appendectomy and has just received pain medication.
B
The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): A. Nursing diagnosis B. Short-term goal C. Long-term goal D. Expected outcome
B
A nurse is caring for a client who is 24 hours postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food". The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity
A
The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of: A. Nursing interventions B. Short-term goals C. Long-term goals D. Expected outcomes.
D
A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing certification. Which of the following should the nurse encourage them to use? (Select all that apply). A. Guided imagery B. Massage therapy C. Meditation D. Music therapy E. Therapeutic touch
A, C, D
The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. A. Used a vague generality B. Did not use the patient's exact words C. Used a "waffle" word (e.g., appears) D. Recorded an inference rather than a cue
A, C, D
A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies? (Select all that apply). A. Art therapy B. Acupressure C. Yoga D. Therapeutic touch E. Biofeedback
A, C, E
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered: A. Obese B. Overweight C. Average D. Underweight
D
A nurse is reviewing the effect of culture on nutrition during a staff in-service. Which of the following groups prescribes eating specific foods to balance forces in the body during illness? (Select all that apply). A. Asian Culture B. African Culture C. Roman Catholicism D. Hispanic/Latinx Culture E. Buddhism
A, D
In which step of the nursing process does the nurse analyze data and identify client problems? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation
B
Mrs. G, an 89-year-old resident of an extended care facility, wears dentures. Her ability to care for herself has recently deteriorated. What should be a concern for the nursing staff related to her dentures? A. Impaired swallowing ability B. Need for adequate mouth care C. Oral pain due to lack of brushing D. Need to do her own AM care
B
A charge nurse observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hours ago. The prescription reads every 4 hours PRN for pain. The nurse administered the medication and checked with the client 40 minutes later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation
A
A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? A. Chamomile B. Ginseng C. Ginger D. Echinacea
A
A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? A. Offer information on a relaxation technique and ask the client if they are interested in trying it. B. Request a social worker see the client to discuss mediation. C. Attempt to use biofeedback techniques with the client. D. Tell the client many people feel the same way before surgery and to think of something else
A
The planning step of the nursing process includes which of the following activities? A. Assessing and diagnosing B. Evaluating goal achievement. C. Performing nursing actions and documenting them. D. Setting goals and selecting interventions.
D
A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he review the medication information? A. Knowledge B. Experience C. Intuition D. Competence
A
A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of a headache. The patient tells the nurse that the medicines prescribed by the tribal healer have done some good. What is the appropriate response of the nurse at this time? A. Tell me about these medicines and how often you are using them. B. I advise you to refrain taking those medicines from the tribal healer. C. Could these medicines cause your headaches? D. Maybe you should increase the frequency of the healer's medicines.
A
A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address" B. "I will review the past medical history on the client's record to get more information" C. "I will carry out the new prescriptions from the provider" D. "I will ask the client if their nausea has resolved"
A
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to their room B. Conduct a client care conference C. Review medical prescriptions D. Develop a plan of care
A
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hours C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing the pain
A
For clients to participate in goal setting, they should be: A. Alert and have some degree of independence. B. Ambulatory and mobile. C. Able to speak and write. D. Able to read and write.
A
How are critical thinking skills and critical thinking attitudes similar? Both are: A. Influences on the nurse's problem solving and decision making B. Like feelings rather than cognitive activities C. Cognitive activities rather than feelings D. Applicable in all aspects of a person's life
A
Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A. Plan is developed for nursing care. B. Physical assessment begins C. List of priorities is determined. D. Review of the assessment is conducted with other team members.
A
The nurse identifies low-risk therapies to a client and should include which therapy(s) in the discussion, except? A. Acupuncture. B. Relaxation. C. Touch. D. Prayer.
A
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? A. Sims' B. Supine C. Dorsal recumbent D. Semi-Fowler's
A
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? A. Sitting upright B. Lying flat on the back with knees flexed C. Lying flat on the back with arms and legs fully extended D. Side-lying with the knees flexed
A
The nursing care plan is: A. A written guideline for implementation and evaluation. B. A documentation of client care. C. A projection of potential alterations in client behaviors D. A tool to set goals and project outcomes.
A
To initiate an intervention the nurse must be competent in three areas, which include: A. Knowledge, function, and specific skills B. Experience, advanced education, and skills. C. Skills, finances, and leadership. D. Leadership, autonomy, and skills.
A
What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: A. Identify personal biases that may affect his thinking and actions B. Identify the most effective interventions for a patient C. Communicate more efficiently with colleagues, patients, and families D. Learn and remember new procedures and techniques
A
When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A. Length of time the current treatment has been in place. B. The spouse's reaction to the client's dressing change. C. Client's concern about the current treatment. D. Physician's reluctance to change the current treatment plan.
A
A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply). A. Explain the roles of other care delivery staff B. Begin discharge planning C. Inform the client that advance directives are required for hospital admission D. Document the client's wishes about organ donation E. Introduce the client to their roommate
A, B, D, E
A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply). A. Ensure that the client has possession of their valuables B. Confirm that the rehabilitation center has a room available at the time of transfer C. Assess how the client tolerates the transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility
A, B, D, E
A nurse is performing a nutrition assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (Select all that apply). A. Poor wound healing B. Dry hair C. Blood pressure 130/80 mmHg D. Weak hand grips E. Impaired coordination
A, B, D, E
A nurse is teaching a group of female clients about risk factors for developing osteoporosis. Which of the following risk factors should the nurse include? (Select all that apply). A. Inactivity B. Family history C. Obesity D. Hyperlipidemia E. Cigarette smoking
A, B, E
A client's wound is not healing and appears to be worsening with the current treatment. The nurse first considers: A. Notifying the physician. B. Calling the wound care nurse C. Changing the wound care treatment. D. Consulting with another nurse.
B
A nurse educator is teaching a class on culture and foods to a group of newly hired nurses. Which of the following statements by a nurse indicates an understanding of the teaching? A. "Most clients who practice Roman Catholicism do not drink caffeinated beverages" B. "Most clients who practice orthodox Judaism do not eat meat with dairy products" C. "Most clients who are Mormon eat only the protein of animals that are slaughtered under strict guidelines" D. "Most clients who practice Hinduism do not eat dairy products"
B
A nurse in a provider's office if collecting data from the caregiver of a 12 month old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of he following domains? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic
B
A nurse is caring for a client who has symptoms of chills, fever, no sweating, headache, nasal congestion, and stiffness and pain in the shoulders, upper back, neck, and back of the head that are common in Chinese culture and is called as syndromes of Wind. This is an example of which of the following? A. Culture shock. B. Culture-bound syndrome. C. Cultural awareness. D. Culture biased.
B
A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. "I will make sure the menu includes kosher options" B. "I will ask the client if they want to schedule some times to pray during the day" C. "I will avoid discussing care when the client's family is around" D. "I will make sure daily communion is available for this client"
B
A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart-healthy diet. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions B. Ask the client to explain how to select or prepare meals C. Encourage the client to fill out an evaluation form about how the nurse presented the information D. Ask whether the client has resources for further instruction on this topic
B
A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique B. The client is able to demonstrate the appropriate technique C. The client states and understanding of the process D. The client is able to write the steps on a piece of paper
B
A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind-body intervention? A. Tell the client the goal of the therapy is to promote healing B. Ask whether the client is comfortable with using prayer. C. Encourage the client participate actively for best results D. Instruct the client to relax during the therapy
B
A nurse on an orthopedic unit is reviewing data for a client who sustained trauma in a motor-vehicle crash. Which of the following values indicates the client is in a catabolic state (using protein faster than protein is being synthesized)? A. Blood albumin 3.5 g/dL B. Negative nitrogen balance C. BMI of 18.5 D. Blood prealbumin 15mg/dL
B
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk-taking D. Creativity
B
How should the nurse modify the examination for a 7-year-old child? A. Ask the parents to leave the room before the examination. B. Demonstrate equipment before using it. C. Allow the child to help with the examination. D. Perform invasive procedures (e.g., otoscopic) last.
B
The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negatively about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let be judgmental of this patient." This best illustrates: A. Theoretical knowledge B. Self-knowledge C. Using reliable resources D. Use of the nursing process
B
The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? A. A client's family attending a diabetic teaching session. B. Canceling physical therapy sessions on the weekend. C. Normal VS and absence of wound infection in a post-op client. D. A client demonstrating accurate medication administration following teaching.
B
The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? A. Dorsal recumbent B. Semi-Fowler's C. Lithotomy D. Sims'
B
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: A. Apply a cold pack to the tibia. B. Elevate the leg 5 inches above the heart. C. Perform range of motion to right leg every 4 hours. D. Administer aspirin 325 mg every 4 hours as needed.
B
When establishing realistic goals, the nurse: A. Bases the goals on the nurse's personal knowledge. B. Knows the resources of the health care facility, family, and the client. C. Must have a client who is physically and emotionally stable. D. Must have the client's cooperation.
B
Which of the following is an example of data that should be validated? A. The urinalysis report indicates there are white blood cells in the urine. B. The client states she feels feverish; you measure the oral temperature at 98°F. C. The client has clear breath sounds; you count a respiratory rate of 18. D. The chest x-ray report indicates the client has pneumonia in the right lower lobe.
B
A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply). A. Find a mentor B. Use a journal to write about the outcomes of clinical judgements. C. Review articles about evidence-based practice. D. Limit consultations with other professionals involved in a client's care. E. Make quick decisions when unsure about a client's needs
B, C, E
A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply). A. Advance directive status B. Follow-up care C. Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home health care agency
B, C, E
A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply). A. Talk to the interpreter about the family while the family is in the room B. Determine client understanding several times during the conversation C. Look at the interpreter when asking the family questions, D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk
B, D, E
A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse demonstrates ethnocentrism? A. Asking the client about some favorite food choices B. Notifying the dietician to complete the menu C. Recommending one's own favorite foods D. Asking the client's family to fill out the menu
C
A nurse is caring for a Chinese client who is hospitalized due to pneumonia. Based on their culture, which of the following is believed to be the cause of the illness? A. An illness is cast by an enemy. B. An illness is a result of punishment for sins. C. An illness may be attributed to overexertion. D. An illness may be given by someone who did not want it.
C
A nurse is caring for a client who has hypertension. Which of the dietary patterns is sometimes followed by Asian clients and places clients at risk for this condition? A. Incorporation of plant-based foods in the diet B. Consumption of raw fruits C. Preparation of foods using sodium D. Focus on shellfish in the diet
C
A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. Members of the same religion share similar feelings about their religion. B. A shared religious background generates mutual regard for one another. C. The same religious beliefs can influence individuals differently. D. The nurse and client should discuss the differences and commonalities in their beliefs.
C
A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that: A. Giving any medication is not allowed. B. Surgery is strictly prohibited. C. Blood products can not be administered. D. Alternative medicines can be advised.
C
A nurse is preparing to deliver a food tray to a Jewish client. The nurse checks the food on the tray and notes that the client has received hamburger and whole milk as a beverage. Which is the appropriate action for the nurse? A. Ask the dietary department to replace the hamburger with crabs. B. Replace the whole milk with fat-free milk. C. Call the dietary department and ask for a new meal tray. D. Deliver the designated food tray to the client.
C
A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incision" B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say"
C
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? A. Ongoing assessment B. Comprehensive physical assessment C. Focused physical assessment D. Psychosocial assessment
C
Arrange the steps of the nursing process in the sequence in which they generally occur. A. Assessment B. Evaluation C. Planning outcomes D. Planning interventions E. Diagnosis A. E, B, A, D, C B. A, B, C, D, E C. A, E, C, D, B D. D, A, B, E, C
C
Planning is a category of nursing behaviors in which: A. The nurse determines the health care needed for the client. B. The Physician determines the plan of care for the client. C. Client-centered goals and expected outcomes are established. D. The client determines the care needed.
C
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? A. An acceptance of the treatment. B. Client understanding of the preoperative procedures. C. Reflecting a cultural value. D. Client agreement to the required procedures.
C
The nurse is providing instructions to a Chinese-American client about the frequency and dosages of the take home medicines. When conducting the teaching, the client continuously turns away from the nurse. The nurse should do which of the following appropriate action? A. Walk around the client so that the nurse can constantly face the client. B. Call the attention of the client by speaking loudly. C. Continue with the instructions, then confirming client's understanding. D. Hand over a written instruction and discuss only what the client doesn't understand.
C
The nurse should use the diaphragm of the stethoscope to auscultate which of the following? A. Heart murmurs B. Jugular venous hums C. Bowel sounds D. Carotid bruits
C
The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain. B. Client will be pain free. C. Client will report pain acuity less than 4 on a scale of 0-10. D. Client will take pain medication every 4 hours around the clock.
C
Which of the following food items would be appropriate for a Jewish client who follows a kosher diet? A. Shrimp and mussels. B. Beef and pork. C. Tuna and salmon. D. Cheese and milk.
C
Which of the following nursing interventions are written correctly? Select all that apply. A. Apply continuous passive motion machine during day. B. Perform neurovascular checks. C. Elevate head of bed 30 degrees before meals. D. Change dressing once a shift.
C
The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: A. Implement the specialist's recommendations. B. Report the recommendations to the primary physician. C. Clarify the suggestions with the client and family members. D. Discuss and review advised strategies with CNS.
D
A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. "I believe in this case you should really make an exception and accept the blood transfusion" B. "I know your family would approve of your decision to have a blood transfusion" C. "Why does your religion mandate that you cannot receive and blood transfusions" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution"
D
A nurse is preparing an instructional session for a client about maintaining stress incontinence. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning B. Select instructional materials C. Identify goals the nurse and the client agree are reasonable D. Determine what the client knows about stress incontinence
D
A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline
D
After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay.
D
As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A. Body mass index B. Usual time for meals and snacks C. Favorite foods D. Any difficulty swallowing
D
In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation
D
Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: A. Physician B. Non Emergent, non-life threatening needs C. Future well-being. D. Urgency of problems
D
