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Fund Final
Potter and Perry end of Chapter questions
| Question | Answer |
|---|---|
| You practice using nursing’s code of ethics for professional registered nurses. This code: | Defines the principles by which nurses provide care to their clients |
| Lacey Conrad, and 18yr old woman, is in the emergency department with fever and cough. The physical asks you to obtain her vital signs, auscultate her lung sounds, listen to her heart, determine her level of comfort, and collect blood and sputum samples f | Assessment |
| Lacey Conrad remains in the emergency department and has developed wheezing and shortness of breath. The physical orders a medical nebulizer treatment now and in 4 hours. Which standard of care are you performing? | Implementation |
| You are caring for a client with end stage lung disease. The client wants to go home on oxygen and be comfortable. The family wants the client to have a new surgical procedure. You explain the risks and benefits of the surgery to the family and discuss th | Advocate |
| Evidence-based practice is defined as: | A problem solving approach to clinical practice based on best practices |
| The examination for RN licensure is exactly the same in every state in the United States. This examination: | Provides a minimal standard of knowledge for practice |
| Contemporary nursing requires that the nurse possess knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? | Caregiver, autonomy and accountability, patient advocate, and health promotion |
| Advanced practice nurses generally: | Function independently |
| Which of the following is the biggest consumer of healthcare? | Federal Government |
| Which of the following was most significant in influencing competition in health care costs? | Prospective payment system |
| A nurse is working in an acute care hospital that uses a case management model. Which of the following activities should the nurse communicate with the case manager? | Coordination of a client transfer to the step down rehabilitation unit |
| Which of the following clients need to be in an extended care facility with skilled nursing? | A severely brain injured client on a ventilator with intravenous medications A young child who recently had a spinal cord injury and is living with quadriplegia and needs to learn a new way of life |
| Which of the following statements is true about evidence based practice? | Assist nurses with meeting standards of practice Helps nurses solve dilemmas in the clinical setting Requires nurses to review and critique research and practice findings |
| Which of the following are population-based interventions for hypertension? | Providing education to prevent hypertension Obtaining a medication prescription and follow-up appointment |
| A client is receiving healthcare by a health care provider who is salaried employee which type of managed care organization (MCO) does the client belong to? | Staff model |
| The overall goal of healthy people 2010 is to: | Increase life expectancy and quality of life and to eliminate health disparities |
| Community health nursing is a nursing approach that merges knowledge from which of the following professional nursing theories? | Population sciences Public health sciences |
| You are caring for a Bosnian community. You identify that the children are under vaccinated and the community is unaware of resources. As you assess the community, you determine that there is a health clinic with a 5 mile radius. You meet the community le | Teaching the community about illnesses Improving the health care of the communities children |
| Vulnerable populations of clients are those who are more likely to develop health problems as a result of: | Excess risks, limits in access to health care services and dependency on others for care |
| Which of the following are major public health problems commonly affecting older adults? | Acute and chronic physical illnesses |
| The local health department received information from the centers for disease control and prevention that the flu was expected to be very contagious this season. You are asked to set flu vaccine clinics in local churches and senior citizen centers. This a | Primary intervention |
| The local school has an increasing number of adolescent parents, and you work with the school district to design and teach classes about infant care, child safety, and time management. These are the examples of which nursing role? | Educator |
| You are practicing in an occupational health setting. There are a large number of employees who smoke, and you design an employee assistance program for smoking cessation. This is an example of which nursing role: | Counselor |
| In your community clinic you care for Lisa, a 40 year old woman who takes insulin to manage her diabetes. She is having increased difficulty in managing her disease, and you want her to try a new insulin pump to help her control her disease. Which of the | Lisa tries the insulin pump on a limited basis Lisa views use of the insulin pump as a simpler way to control her blood sugars The insulin pump is compatible with Lisa’s existing needs, values, and past experiences. Lisa perceives the insulin pump as m |
| What are the three elements that are included in a community assessment? | Structure or locale, people, and social systems |
| Abby smith is a parish nurse for her Catholic church. The first Sunday of every month she has a free blood pressure screening. She is providing what level of prevention? | Primary prevention |
| Mr. Jones is 72 years old and was diagnosed with chronic obstructive pulmonary disease 5 years ago. For the last two years, he has been participating in a pulmonary rehabilitation exercise class offered by the local hospital at a fitness facility. This is | Tertiary prevention |
| Based on the transtheoretical model of change, what is the most appropriate response to a client, Ms. Johnson, who states: “Me exercise? I haven’t done that since junior high gym class, and I hated it then!” | “I understand. Can you think of one reason why being more active would be helpful for you?” |
| The previous client, Ms. Johnson, returns to your clinic the next month and states: “ I have noticed how many people are out walking in my neighborhood. Is walking good for you?” What is the best response to help Ms. Johnson through the stages of change f | “Yes, walking is great exercise. Do you think you could go for a 5 minute walk this next week?” |
| Mr. Brown has been laid off and has many bills needing to be paid. He is going through a divorce from his marriage of 15 years and has been seeing his pastor. He does not have a primary health care provider because he has never really been sick and his pa | Increased stress in his life with the divorce and the loss of a job |
| The previous client, Mr. Brown, is being seen in the clinic today with concerns regarding weight loss and a frequent burning sensation in his throat. Rob Miller is the nurse today. In his care of Mr. Brown, after Rob’s initial assessment, he would tell th | “I think Mr. Brown is struggling with his loss of income and his loss of his role as husband. It will be important to refer him for guidance with his losses” |
| When taking care of clients, Nurse Olson routinely asks clients if they take any vitamins or herbal medications. She encourages family members to bring in music that the client likes to help the client relax. She also frequently prays with her clients if | Holistic |
| When illness does occur, different attitudes about illness cause people to react in different ways. Medical sociologists call the reaction to illness: | Illness behavior |
| The health belief model addresses the relationship between a person’s belief and behavior, thus: | It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies |
| Karen smith works in a special care unit in Denver, Colorado, for children with severe immunology problems. Today she is caring for 3-year-old boy from Greece. The boy’s father is with him, while his mother and sister are back in Greece. Karen is having d | Search for help interpretation and understanding of the cultural differences by contacting someone from the Greek community in Denver. |
| During change-of-shift report the night nurse states, “Mr. Sierra told me that he has had a bad experience with surgery in the past. I did not get a chance to ask him about it. We had a number of clients requiring procedures last night. He seems a bit anx | Discipline |
| When you enter Mr. Ryan’s room, he tells you, “I am not happy with the way the client care technician did my bath. He just seemed to be in a hurry and did not wash my back like I asked.” You decide to go talk with the technician to learn his side of the s | Fairness |
| The surgical unit has initiated the use of a pain rating scale, which is to be used to access clients’ pain severity during their postoperative recovery. Susan, the registered nurse (RN) assigned to Ms. Wills’ looks at the pain flow sheet to see Ms. Wills | Consistent |
| During the day the nurse spends time instructing a client in how to self-administer insulin. After discussing the techniques and demonstrating an injection, the nurse has the client to try it. After two attempts the client obviously does not understand ho | Problem solving |
| A nurse uses an institution’s procedure manual to confirm how to insert a Foley catheter. The level of critical thinking the nurse is using: | Basic critical thinking |
| A client had a hip surgery 24 hours ago. The nurse refers to the written plan of care, noting that the client has a drainage device exceeds 100 mL for the day. When the nurse enters the room, the nurse looks at the device and carefully notes the amount of | Assessment |
| The nurse asks a client how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description in his textbook of loss and grief in addition to therapeutic communication principles. The critical thinking comp | Knowledge application |
| The purpose of assessment is to: | Establish a database concerning the client |
| Assessment data must be descriptive, concise, and complete. An assessment should NOT include: | Inferences or interpretive statements not supported with data |
| A nurse assesses a client who comes to the pulmonary clinic. “Tell me what medications you are on for your breathing problem. I see from your last visit that Dr. Russell recommended routine exercise. Can you also tell me how successful you have been follo | Health perception-health management pattern |
| The nurse asks the client, “Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?” this is a series of questions would likely occur during which phrase of a client inte | Working |
| During data base clustering a nurse: | Organizes cues into patterns that lead to identifying nursing diagnoses |
| What type of interview techniques does the nurse use when asking the question, “Do you have pain or cramping?” | Closed-ended questioning |
| What techniques encourage a client to tell his or her full story? | Active listening, Back channeling, Use of open-ended questions |
| You gather the following assessment data. Which of the following cues form a pattern? | Client is restless; Client states feel short of breath, Respirations are 24 per minute and irregular |
| An emergency department nurse is caring for a client who was severely injured in a car accident. The client’s family is waiting in the room. They are crying softly. The nurse sits down next to the family, takes the mother’s hand, and says, “I can only ima | Presence |
| A client states that he does not believe in the existence of God. This client mostly like is an: | Atheist |
| As the nurse cares for a client in an outpatient clinic, the client states that he recently lost his position as a volunteer coordinator at a local community center. He expresses that he is angry with his former boss and with God. The nurse knows the prio | Vocation |
| A client who is hospitalized with congestive heart failure states that she sees her illness as an opportunity and a challenge. Despite her illness, she is still able to see that life is worth living. This is an example of: | Hope |
| Which of the following statements made by an older adult woman whose husband recently died most indicates that need for follow-up by the nurse? | “I have been unable to talk with my children lately” |
| Which of the following nursing inventions support a healing relationship with a client? | Praying with the client, Helping a client see positive aspects related to a chronic illness |
| A client expresses the desire to learn how to meditate. What does the nurse need to do first? | Select a teaching environment that is free from distractions |
| An older adult is receiving hospice care. What nursing interventions will help the client cope with the feelings related to death and dying? | Teaching the client how to use guided imaginary, encouraging the family to visit the client frequently, Helping the client put significant photographs in a scrapbook for the family |
| The nurse is gathering a sleep history from a client who is being evaluated for obstructive sleep apnea. What common symptom will the client most likely report? | Excessive daytime sleepiness |
| The nurse incorporates what priority nursing invention into a plan of care to promote sleep for a hospitalized client? | Avoid awakening client for nonessential tasks. |
| Older adults are cautioned about the long-term use of sedatives and hypnotics because these medications can: | Lead to sleep disruption |
| The nurse is providing health teaching for a client using herbal compounds such as valerian for sleep. What points need to be included? | Should not be used indefinitely, may interfere with prescribed medications, Can lead to further sleep problems over time, are not regulated by the U.S. food and drug administration (FDA) |
| The client reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that the vivid dreaming occurs during which sleep phrase? | REM sleep |
| The nurse teaches a client taking phenytoin (Dilantin), an anticonvulsant, that this group of medications causes which symptom of a sleep problem? | Increased daytime sleepiness |
| Which intervention is appropriate to include on a care plan for improving sleeping in the older adult? | Decrease fluids 2 to 4 hours before sleep |
| Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching? | “My grandmother told me that babies sleep better on their stomachs.” |
| The nurse is developing a plan of care for a client experiencing narcolepsy. Which intervention is appropriate to include on the plan? | Encourage client to take one or two 20-minute naps during the day. |
| What nursing measure promotes sleep in school age children? | Encourage quiet activities before bedtime |
| Marina is a 6 year old child from Mexico, Marias socialization into the Mexican culture is best described as: | Enculturation |
| A 46 year old woman from Bosnia came to the United States 6 years ago. Although she did not celebrate Christmas when she lived in Bosnia, she celebrates Christmas with her family now. This woman has experienced assimilation into the culture of the United | Adapted to and adopted the American Culture |
| Brooke is a nursing student, in order for Brooke to enhance her cultural awareness, she will need to make an in-depth self- examination of her: | Background, recognizing her biases and prejudices |
| Cultural competence is the process of: | Acquiring specific knowledge, skills and attitudes |
| Ken is an RN caring for Mr. DeRosa, Ken has determined Mr DeRosa is from Russian heritage. Ken has a Russian neighbor who does not keep his property well maintained. Ken tells Mr. DeRosa, “While you are in the rehabilitation center, you will keep your bed | Ethnocentrism |
| When action is taken on ones prejudices: | Discrimination occurs |
| Jane is a nursing student who is doing her community health rotation in an inner city public health department. When she investigates sociodemographic and health data of the people served by the health department, Jane detects disparities in health outcom | Influence of socioeconomic factors in morbidity and mortality |
| Culture strongly influences pain expression and need for pain medication. However cultural pain: | May be suffered by a client whose valued way of life is disregarded by practitioners |
| The dominant values in American society on individual autonomy and self -determination: | May be in direct conflict with diverse groups |
| Which two factors contribute to the projected increase in the number of older adults? | The aging of the baby boom generation and the growth of the population segment over 85 |
| Which of the following is true about the theories of aging? | There is no single theory that explains aging |
| The three common conditions affecting cognition in older adults are: | Delirium, depression and dementia |
| Sexuality is recognized as a factor in the care of older adults, thus: | All older adults, whether healthy or frail, need to express sexual feelings |
| Older adults experience a change in sexuality activity. Which best explains this change? | Frequency and opportunities for sexual activity may decline |
| Visual acuity declines with age. Presbyopia is a progressive decline in: | The ability of the eyes to accommodate for close, detailed work |
| A common age related change in auditory acuity is called: | Presbycusis |
| Taste buds atrophy and lose sensitivity, and appetite may decrease. The older adult is less able to discern: | Salty, sour and bitter tastes |
| Kyphosis, a change in the musculoskeletal system leads to: | Changes in the configuration of the spine that affect the lungs and thorax |
| The nurse conducts a general survey on an adult client, which includes: | Appearance and behavior |
| To correctly palpate the clients’ skin for temperature, the nurse uses: | Dorsal surface of the hands |
| To assess a client’s superficial lymph nodes, the nurse: | Gently palpates using the pads of the index and middle fingers |
| The nurse is teaching the client to inspect all skin surfaces and to report pigmented skin lesions that: | Have irregular borders |
| To auscultate the lung fields, the nurse uses systematic pattern comparing: | Side to side |
| The clients’ respiratory assessment reveals a loud, low pitched, rumbling coarse sound heard during inspiration and expiration. The nurse interprets these sounds as: | Rhonchi |
| While auscultating heart sounds, the nurse documents that s2 is best heard at the base. This sound (S2) correlates with closure of the: | Aortic and pulmonic valves |
| To assess the clients’ dorsalis pedis pulse, the nurse palpates: | Lateral to the extensor tendon of the great toe |
| To spread breast tissue evenly over the chest wall during an examination, the nurse asks the client to lie supine with: | The ipsilateral arm overhead with a small pillow under the shoulder |
| Place in order the assessment techniques employed during an abdominal examination. | Inspection, auscultation, palpation, and percussion |
| The nurse is teaching a client how to perform a testicular self-examination. The nurse informs the client: | “Contact your health care provider if you feel pain-less pea size nodule” |
| The client is being assessed for range of joint movement. You ask the client to move the arm toward the body, evaluating the movement of: | Adduction |
| The nurse asks the client to interpret the saying, “Don’t count your chickens before they’re hatched.” The clients response reveals: | Abstract reasoning |
| The nurse asks the client to shrug the shoulders and turn the head side to side against the resistance of the examiners hand; these actions evaluate cranial nerve number: | XI-Spinal accessory |
| If the infectious disease can be transmitted directly from one person to another , it is a: | Communicable disease |
| Infectious diseases such as hepatitis B or C become a reservoir for pathogens in: | Blood |
| The interval when a client manifests signs and symptoms specific to a type of infection is the: | Illness stage |
| The most effective way to break the chain of infection is by: | Hand hygiene |
| After coming in contact with infected clients, and after handling contaminated equipment or organic material, visitors are encouraged to: | Perform hand hygiene before eating or handling food |
| A client is isolated for pulmonary tuberculosis. The nurse notes the client seems to be angry but he knows this is a normal response to isolation. The best intervention is to: | Explain the reasons for isolation procedures and provide meaningful stimulation |
| A gown should be worn when: | Blood or body fluids may get on the nurses clothing from a task the nurse plans to perform |
| The nurse has redressed a client’s wound and now plans to administer a medication to the client. It is important to: | Remove gloves and perform hand hygiene before administering the medication |
| When a nurse is performing surgical hand asepsis, the nurse must keep hands: | Above elbows |
| To sterilize surgical instruments, parenteral solutions and surgical dressings: | An autoclave is used |
| The nurse is having difficulty reading a physician’s order for a medication. The nurse knows the physician is very busy and does not like to be called. The nurse should: | Call the physician to have the order clarified |
| The client has an order for 2 tablespoons of Milk of Magnesia. The nurse converts this does to the metric system and gives the client: | 30mL |
| Most medication errors occur when the nurse: | Fails to follow routine procedures |
| A client is to receive cephalexin (Keflex) 500mg PO. The pharmacy has sent 250mg tablets. The nurse gives: | 2 Tablets |
| When identifying a new client before administering medication, the nurse asks the client to state his name. The client does not state the correct name. The nurse asks again, and the client still states another name. What is the nurses best next action? | Investigate the clients mental status before administering any further medications |
| A client is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority, in relation to safe medication administration, for the discharge nurse? | Ensure the home care agency is aware of medication and health teaching needs |
| A nursing student takes a clients antibiotic to his room. The client asks the nursing student what it is and why he should take it. The nursing students reply includes the following information: | The name of the medication and description of its desired effect |
| The nurse is administering a sustained release capsule to a new client. The client insists that he cannot swallow pills. The best course of action for the nurse is to: | Ask the physician to change the order |
| The nurse takes a medication to the client, and the client tells the nurse to take it away becuase she is not going to take it. The nurses’ first action should be to: | Ask the clients’ reasons for refusal |
| The nurse selects the route for administering medication according to: | The prescriber’s orders |
| A client is receiving and IV push medication. If this type of drug infiltrates into the outer tissues, the nurse will: | Follow a facility policy or drug manufacturer’s directions |
| If a client is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects | Phlebitis |
| In the United States, access to health care usually depends on a client’s ability to pay. The client tneeds a liver transplant to survive. This client has been out of work for several months. A discussion about the ethics of this situation would involve p | Justice, because the first and greatest question in this situation is how to determine the just distribution of resources |
| It may seem redundant that health care providers, including professional nurses, agree to “do no harm” to their clients. The point of this agreement is to reassure the public that in all ways the health care team will not only work to heal clients, they a | Nonmaleficence |
| A child’s immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and for society, outweigh the temporary discomforts. This involves the principle of: | Beneficence |
| If a nurse assesses a client for pain and then offers a plan to manage the pain the principle that encourages the nurse to monitor the client’s response to the plan is: | Fidelity (the promise) |
| Nurses agree to be advocates for their clients. Practice of advocacy calls for the nurse to: | Assess the client’s point of view and prepare to articulate this point of view |
| Successful ethical discussion depends on people who have a clear sense of personal values. When many people share the same values, it may seem possible to identify a philosophy of utilitarianism, which proposes that: | The value of something is determined by its usefulness |
| The philosophy sometimes called the ethnic of care suggests that ethical dilemmas can best be solved by attention to: | Relationships |
| In most ethical dilemmas the solution to the dilemma requires negotiation among members of the health care team. The nurse’s point of view is valuable because: | Nurses develop a relationship to the client that is unique among all professional health care providers |
| Ethical dilemmas often arise over a conflict of opinion. Once the nurse has determined that the dilemma is ethical, a critical first step in negotiating the difference of opinion would be to: | Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma |
| A nurse works in a cardiac unit. She is taking care of a client who recently had coronary bypass surgery. Which of the following represent legal sources of standards of care nurses use to deliver safe health care? | Policies and procedures of the employing hospital Nurse Practice Act of the state the nurse is working in Regulations identified in the Joint Commissions manual The American Nurses Association standards of nursing practice |
| A nurse is sued for failure to monitor a client appropriately. Which statements are correct about professional negligence lawsuits? | The person filing the lawsuit has the burden of proof The plaintiff must prove that a breach in the prevailing standard of care caused an injury |
| When the nurse stops to help in an emergency at the scene of an accident, if the injured party files suit and the nurse’s employing institution’s insurance does not cover the nurse, the nurse would probably be covered by: | The Good Samaritan law, which grant immunity from suit if there is no gross negligence |
| Even though the nurse may obtain the clients signature on a form, obtaining informed consent is the responsibility of the: | Physician |
| The Legal definition of death that facilitates organ donation is cessation of: | Functions of the entire brain |
| The nurse notes that an advance directive is on the clients’ medical record. Which of the following statements represents the best description of guidelines a nurse would follow? | A living will invoked only when the client has a terminal condition or in a persistent vegetative state |
| A nurse notes that the health care unit keeps a listing of the clients’ names at the front desk in easy view for health care providers to more efficiently locate the client. The nurse knows that this action would be a violation of: | HIPPA Health Insurance Portability and Accountability Act |
| Which of the following statements represent actions that may result in a registered nurses receiving either disciplinary action by the nurses State Board of Nursing or revocation of the nurses professional license? | Taking or selling controlled substances Applying physical restraints without a written physicians order |
| HIPPA provides clients basic rights pertaining to their medical records. Which statement reflects a violation of HIPPA? | Posting daily nursing care information along with the medical condition of the client on a message board in the clients room |
| The nurse must follow standards of care to avoid potential litigation and suits of negligence. Which of the following statements represents a potential nursing malpractice situation? | Failure to make a nursing diagnosis Failure to provide discharge instructions Failure to follow the six rights of medication administration Failure to use proper medical equipment ordered for client monitoring Failure to questions a health care provid |
| The physiological changes that occur during the aging process increase the older clients risk for: | Falls and Burns |
| You discover an electrical fire in a client’s room. Your first action would be to: | Evacuate any clients or visitors in immediate danger |
| A parent calls the pediatricians’ office frantic about the bottle of cleaner that her 2 year old son drank. Which of the following is the most important instruction you can give this parent? | Call the poison control center |
| A couple is with their adolescent daughter for a school physical. The parents tell you that they are worried about all the safety risks affecting this age. As you plan to teach the parents about these risks, you remember that adolescents are at a greater | Automobile accidents, suicide, and substance abuse |
| During the night a shift client is found wandering the hospital halls looking for a bathroom. The nurses initial intervention would be to: | Provide scheduled toileting during the night shift |
| Lisa, a nurse assistant, is working with you during your shift. One of your clients has upper limb restraints. In delegating care of this client to Lisa, you would tell her to: | Report and signs of redness, excoriation, or constriction of circulation under the restraint |
| The family of your confused, ambulatory client insists that all four side rails be up when the client is alone. The best way to handle this situation would be to: | Inform them of the risks associated with side rail use |
| During your assessment of a 56 year old man, he reports increased alcohol consumption due to stress at work. One of your expected outcomes for this client will be to: | Provide the client with resources for stress management classes |
| Health care workers who have direct contact with individuals suspected of being contaminated with anthrax should: | Have the client remove clothing and place in a sealed biohazard bag Wear an isolation gown, gloves, and high efficiency particulate air (HEPA) mask |
| A child you are caring for in the hospital starts to have a grand mal seizure while playing in the playroom. What is the most important intervention you can do during this situation? | Clear the area around the child to protect the child from injury |
| Mr. Stone has been on bed rest for several days. When he attempted to walk with assistance, he became dizzy and nauseated. These are most likely symptoms of which of the following? | Orthostatic Hypotension |
| What are the appropriate actions for Mr. Stone? | Call for assistance Allow Mr. Stone to sit down Take Mr. Stone’s blood pressure and pulse |
| Which area in the nervous system controls balance? | Cerebellum and inner ear |
| When a client has a right-sided cerebral hemorrhage, what may also be present? | Left-sided hemiplegia |
| In which of the following maturational processes is the greatest change observed? | Childhood and old age |
| Clients are more open to developing an exercise program if they are: | At the stage of readiness to change their behavior |
| Which is the result of children being less physically active? | An increase in obesity |
| A principle of good body mechanics includes which of the following concepts? | Maintaining a wide base of support and bending at the knees |
| A client begins to fall during ambulation. How would the nurse prevent injury to the client? | Slide the client down the nurses’ body and leg to the floor |
| Which of the following laboratory values would you expect in a client experiencing prolonged immobility? | Elevated calcium |
| A client has been on bed rest for several days. The client stands, and the nurse notes the client’s systolic pressure drops 20mmhg. Which of the following should the nurse document in the medical record? | Orthostatic hypotension |
| The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to: | Facilitate the return of venous blood to the heart |
| You are caring for a client who has osteoporosis. The nurse is teaching her about ways to prevent fractures. Which of the following client statements reflects a need for further education? | “The more frequently I walk, the more likely I will be able to fall and break my leg. I think I will get a wheelchair so I don’t have to walk anymore.” |
| The client at greatest risk for developing adverse effects of immobility is a: | 78-yr-old man in traction for a broken hip |
| A client who was in a car accident and broke his femur has been immobilized for 5 days. When the nurse gets this client out of bed for the first time, a nursing diagnosis related to the safety of this client will be: | Risk for activity intolerance |
| A client has a left-sided cerebral accident 3 days ago and is receiving 5000U of heparin SQ q 12 h to prevent thrombophlebitis. The client is receiving enteral feeding through a small bore nasogastric tube because of dysphagia. Which of the following symp | Hematuria |
| A home care nurse is preparing the home for a client who is going home following a left hip replacement. The client is cooperative and can partially bear weight. What should the nurse order from the home medical supply company to help the client move from | A small transfer board |
| The nurse is caring for a client who has right-sided weakness. The nurse needs to help the client walk. What should the nurse do while walking with the client? | Put a gait belt on the client to provide support on the right side |
| Before transferring a client from the bed to a stretcher, which assessment data does the nurse need to gather? | The clients’ weight How cooperative the client is The presence of IV tubes |
| You are teaching a client about healthy nutrition. You recognize that the client understands the teaching when he states: | I will make sure that I eat a balanced diet and exercise regularly |
| As a nurse, you will teach a client who has had surgery to increase which nutrient to help with tissue repair? | Protein |
| You are caring for a client experiencing dysphagia. Which interventions will decrease the risk of aspiration during feeding? | Sit the client upright in a chair Place food in the strong side of the mouth Feed the client slowly, allowing time to chew and swallow |
| The nurse suspects that the client receiving PN through a CVC has an air embolus. Which action does the nurse need to take first? | Turn client to left lateral decubitas position |
| Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube? | Place an order for an x-ray examination to check position |
| The catheter of a client receiving PN becomes occluded. Order the steps for caring for the occluded catheter in the order in which you would perform them. | Temporarily stop the infusion, Flush the line with saline or heparin, attempt to aspirate the clot, use a thrombolytic agent if ordered or per protocol |
| Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a client suspected of having PUD? | Helicobacter pylori |
| You are assessing a client receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention? | Gastric residual aspirate of 300 mL for the second consecutive time |
| The home care nurse is seeing the following clients. Which client is at greatest risk for experiencing inadequate nutrition? | A recently widowed 76 year old woman recovering from a mild stroke |
| When repositioning an immobile client, the nurse notices redness over the bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating: | Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area |
| This type of pressure ulcer has been an observable pressure related alteration of intact skin whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolne | Stage 1 |
| When obtaining a wound culture to determine the presence of a wound infection, the specimen should be taken from the: | Wound after it has first been cleansed with normal saline |
| Postoperatively the client with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct interven | Cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration |
| Serous drainage from a wound is defined as: | Clear, watery plasma |
| For a client who has a muscle sprain, localized hemorrhage, or hematoma, what wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? | Ice bag |
| Interventions to manage a client who is experiencing fecal and urinary incontinence include: | Utilization of an incontinence cleanser, followed by an application of a moisture barrier ointment |
| The best description of a hydrocolloid dressing is: | A dressing that forms a gel that interacts with the wound surface |
| A binder placed around a surgical client with a new abdominal wound is indicated for: | Reduction of stress on the abdominal incision |
| Application of a warm compress is indicated: | To improve blood flow to an injured part |
| A female client reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean voided specimen is markedly cloudy. The probable cause of these symptoms and findings is: | Cystitis |
| The urine appears to be concentrated and cloudy because of the presence of white blood cells or: | Bacteria |
| Elimination changes that result from obstruction to the flow of urine in the urinary collecting system may cause which of the following? | Renal damage Urinary retention Urinary tract infection |
| Health care-acquired UTI’s are often related to poor hand washing and: | Improper catheter care |
| Some medications change the color of urine. Pyridium colors the urine: | Bright orange to rust |
| To minimize nocturia, clients should avoid fluids: | 2 hours before bedtime |
| Maintaining a Foley catheter drainage bag in the dependent position prevents: | Urinary reflux |
| When applying a condom catheter, it is important to secure the catheter on the penile shaft in such a manner that the catheter is: | Snug and secure, but does not cause constriction to blood flow |
| After a transurethral prostatectomy a client returns to his room with a triple lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150ml/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8 h | 1320 mL / 8 hour period |
| The client undergoes a kidney ultrasound examination. The nurse providing post-procedure care remembers: | That there are no special precautions |
| Most nutrients and electrolytes are absorbed in the: | Small intestine |
| During the nursing assessment the client reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms might be associated with: | Lactose intolerance |
| In assessing a 55 year old client who is in the clinic for a routine physical, instruct the client about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT): | As part of a routine examination for colon cancer |
| Which of the following medications listed in a client’s medication history may cause gastrointestinal bleeding? | Aspirin Nonsteroidal anti-inflammatory drugs |
| Diarrhea that occurs with a fecal impaction is the result of: | Seepage of stool around the impaction |
| A cleansing enema is ordered for a 55 year old client before intestinal surgery. The maximum amount of fluid given is: | 750 to 1000ml |
| During the enema the client begins to complain of pain. The nurse notes blood in the return fluid and rectal bleeding. The nurses’ actions are to: | Stop the instillation and obtain vital signs |
| Number the steps to irrigating a nasogastric tube in correct order: | Perform hand hygiene, and apply clean gloves Insert tip of syringe into NG tube, and slowly inject 30 mL saline Reconnect the NG tube to suction Slowly aspirate the syringe Clamp and disconnect the NG tube |
| List the correct order in which to apply an ostomy pouch: | Perform hand hygiene, and apply clean gloves Remove the used pouch and skin barrier Assess the stoma for color, swelling and healing Gently cleanse the peristomal skin with warm tap water Cut an opening on the pouch 1/16 inch larger than the stoma Pr |
| A nurse specially educated to care for ostomy clients is an: | Wound ostomy continence nurse |
| A client is admitted to the hospital with a history of vomiting for 2 days and diminished oral intake. Arterial blood gas levels on admission are pH, 7.30; PaCO2, 36 mm hg; PaO2, 92 mm hg; and HCO3,18. You understand that the clients’ acid base imbalance | Metabolic acidosis |
| A client with cardiac history is taking a potassium wasting diuretic (furosemide) and is seen in the emergency department for complaints of weakness. You expect to evaluate which laboratory values? | Potassium and blood glucose |
| Which of these clients should the nurse see first for possibly life threatening fluid volume excess? | A 65 year old client recently diagnosed with CHF |
| A client has the following blood gas levels: pH, 7.52; PaCO2, 28mmhg; PaO2, 92mmhg;HCO3,17 mEq/L. you would expect the health care provider to order? | Deep breathing exercises to ease respiratory effort |
| You assess four clients. Which client is at greatest risk for the development of hypocalcemia? | 56 –year- old with acute renal failure |
| Which of the following activities can be successfully delegated to nursing assistive personnel? | Measuring intake and output Reporting an IV container that is low in fluid |
| Many factors are initially controlled for in the IV insertion procedure. Place the following steps for IV infusion in the correct order. | Carefully check the health care providers order for the IV therapy Ensure the six rights of medication administration Assess the client experience with IV therapy Assess for risk factors, such as age or platelet count Perform hand hygiene Open and pr |
| Assessment of IV fluid infiltration includes: | Edema and pain, and pallor and coolness |
| Clinical assessment of dehydration would be confirmed if you identified: | Dry mucous membranes |
| Which of the following signs or symptoms in an opioid naïve client is of the greatest concern to the nurse when assessing the client 1 hour after administering an opioid? | Difficulty arousing the client |
| A physician writes the following order on an opioid naïve client who returned from the operating room following a total hip replacement. “Fentanyl patch 100 mcg, change every 3 days.” Based on this order the nurse takes the following action: | Call the physician and question the order |
| A client is being discharged home on an ATC opioid for chronic back pain. Because of this order, which class of medication does the nurse request an order for? | Stimulant laxative |
| An intern new to the service writes an order for OxyContin SR 10mg PO q12 hour’s prn. Which part of the order does the nurse question? | The time interval |
| After returning from vacation, the nurse notices that her client has been receiving Percocet (5/325), two tablets PO every 3 hours for the past 3 days. What is the nurse most concerned about? | The amount of daily acetaminophen |
| A client with chronic low back pain who was receiving an opioid ATC for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking, chills, abdominal cramps, and joint pain. The nurse recognizes that this c | Physical dependence |
| After having received 0.2 mg of naloxone IVP, a client’s respiratory rate and depth are within normal limits. The nurse now plans to implement the following action: | Assess client’s vital signs every 15 minutes for 2 hours |
| Which one of the following instructions is crucial for the nurse to give to both family and the client who is about to be started on a PCA of morphine? | Only the client should push the button |
| A client with a history of stroke that left her confused and unable to communicate has returned from interventional radiology following placement of a gastrostomy tube. The physicians order reads as follows: “Vicodin 1 tab, per tube, q4 hours, prn.” Which | Request to have the order changed to ATC for the first 48 hours |
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