UltraField2899
The nurse is contributing to a staff education program about…
The nurse is contributing to a staff education program about advance directives. Which of the following information should the nurse suggest including? Select all that
apply.
“The power of attorney for health care is a document that designates the person that the client appoints to make health care decisions when the client is unable
to do so.
“A living will and a power of attorney for health care document are the same type of advance directive.
“A living will may indicate if the client wishes to receive treatments such as mechanical ventilation.
“The power of attorney for health care document should be witnessed by an attorney.”
“At each admission. clients should be asked if the client has an advance directive.’
The nurse is caring for assigned clients. The nurse should recognize that a referral to a respiratory therapist should be recommended for the client
01 with Gulllain-Barre who is experiencing shortness of breath
02 with multiple sclerosis (MS) who needs assistance with brushing the teeth because of muscle spasticity
03. who had a stroke 24 hours ago and is experiencing dysphagia
04 who had a spinal cord injury 48 hours ago at L4 and requires a cyclic pressure-relief device while in a wheelchair
The nurse is planning a staff education program about transferring clients within and between health care settings. Which of the following information should the nurse
include?
“Transferring the client to a higher level of care helps reduce the stress
and anxiety felt by the client’s familv.”
“The nurse transferring the client to another unit or facility provides a verbal report to the nurse receiving the client.”
Transferring the client to another facility includes sending the client’s original medical record with the client.
“The nurse discharging the client to another-facility is responsible for planning the physical move of the client.”
The nurse is caring for a client with diabetes mellitus (type 1) who is experiencing new-onset confusion, tremors and diaphoresis. Which of the following actions would be a
priority for the nurse to take?
Initiate seizure precautions.
Administer glucose tablets prescribed p.r.n.
Provide the client with a complex carbohydrate snack.
Check the client’s most recent glycosylated hemoglobih (HgbA, C) level.
The nurse has attended a staff education program about medication reconciliation. The nurse should recognize that medication reconciliation
assesses the client’s ability to obtain medications
should be completed only during the client’s admission or discharge
includes communicating with the client about changes in the medication prescriptions
involves reviewing the client’s most recent laboratory test results to assess renal and liver function
The nurse is caring for a client who is receiving 1 L of 5% dextrose in water to be infused over 8 hours. The nurse has tubing with a drop factor of 15 available. How many
git/min should the client receive? Record your answer using a whole number.
gtt/min
The nurse is caring for a client who had a total hip arthroplasty 1 day ago. The nurse is scheduling a meeting with the interdisciplinary team to discuss the client’s discharge
planning. Which of the following elements are key to ensuring a collaborative process? Select all that apply.
utilizing effective communication skills
demonstrating respect for other health care team members
avoiding self-awareness of the nurse’s limitations as a team member
maintaining ownership of all health care responsibilities and tasks
sharing steps of the decision-making process
The nurse is talking with a client who has heart failure and is receiving digoxin. Which of the following statements by the client would require follow-up?
01″I am experiencing a loss or appetite
02.”I take mv oulse before takina digoxin.
03″I have stopped taking herbal supplements, such as St. John’s wort.”
04″I take digoxin 2 hours after a meal.”
The nurse is obtaining a health history from a female client who has a new prescription for a combined oral contraceptive. It would require follow-up if the client reports
a history of acne vulgaris
a history of migraine headaches with an aura
a 2-year-old child from a previous pregnancy
blood pressure that is tvpicallv around 110/60 mm Ha
The nurse is obtaining a health history from a female client who has a new prescription for a combined oral contraceptive. It would require follow-up if the client reports
a history of acne vulgaris
a history of migraine headaches with an aura
a 2-year-old child from a previous pregnancy
blood pressure that is typically around 110/60 mm Hg
The nurse has attended a staff development conference about preventing falls in a health care facility. Which of the following statements by the nurse would indicate a correct understanding of the conference? Select all that apply
“I will leave the lights on in the client’s room at all times.
“I will keep the client’s bed locked and in the low position.
I should immediately notify the client’s family of any changes in the client’s cognition
I may restrain the client if the client attempts to leave the bed without using the call light.
“I can provide non-skid footwear and encourage the client to wear the non-skid footwear while out of bed.”
I should promptly answer the client’s call light.
The nurse has attended a staff development conference about preventing falls in a health care facility. Which of the following statements by the nurse would indicate a
correct understanding of the conference? Select all that apply
01″I will leave the lights on in the client’s room at all times
02″I will keep the client’s bed locked and in the low position.
03″I should immediately notify the client’s family of any changes in the client’s cognition.
04″I may restrain the client if the client attempts to leave the bed without using the call light.”
05.”I can provide non-skid footwear and encourage the client to wear the non-skid footwear while out of bed.”
06″I should promptly answer the client’s call light.”
The nurse has reinforced teaching with a client who has hypertension about recommended dietary sodium restrictions. Which of the following statements by the client would
indicate a correct understanding of the teaching?
01″I can continue to enjoy my daily glass of tomato juice.”
02″I will eliminate the jelly from my peanut butter sandwiches.”
03.”I will switch from readv-to-eat oat cereal to hot oatmeal for breakfast.”
04″I should substitute processed cheese spread for the cheddar cheese in my recipes.”
The nurse manager Is discussing a recent incident with a visibly upset staff nurse. The staff nurse states, You do not have all of the information. I will fix this problem
myself.” The nurse manager understands that the staff nurse is attempting to manage
intergroup conflict by using a compromise approach
intergroup conflict by using a collaborative approach
interpersonal conflict by using a competitive approach
interpersonal conflict by using an accommodating approach
The nurse has received the following information about assigned clients. The nurse should first assess the client with a spinal cord injury at
01. C6 who reports nasal congestion and a pounding headache
02. T7 who has moist skin and a pressure ulcer (Stage I) on the right heel
03. T12 who reports numbness and tingling in the legs while standing with a full leg brace
04. C4 who has a halo traction device and is reporting redness from 1 of the 4 pin sites
The nurse is caring for assigned clients. The nurse should implement contact precautions for the client who has
active pulmonary tuberculosis (TB)
Rubella
pertussis
respiratory syncytial virus (RSV)
The nurse is caring for a client with mycoplasma pneumonia. Which of the following infection control precautions should the nurse implement? Select all that apply
Place the client in a private room
Limit the client’s visitors to one 30-minute visit each shift
Wear clean gloves when delivering the clients meal tray.
Wear a surgical mask when obtaining the client’s blood pressure
Place a surgical mask on the client being transported outside the assigned room
The nurse is teaching a client who is receiving newly prescribed enalapril. Which of the following information should the nurse include?
01.”Avoid driving for the first day after starting the medication.”
02″Avoid seasoning your food with salt substitutes while taking the medication.
03.”Have a blood specimen obtained in one month to check your serum calcium level.’
04″Check your blood pressure once every month and notify your primary health care provider of significant changes.”
The nurse is collecting data from a client who is scheduled for a paracentesis in 1 hour. Which of the following questions would be important for the nurse to ask?
01″Did you have anything to eat or drink in the past 6 hours?”
02″Can you lie flat on your back for at least 4 hours?”
03″Are you taking any anticoagulant medications?”
04″Are you allergic to iodine or shellfish?”
The nurse has received the following information about assigned clients. The nurse should first collect data on the client who has
01not voided for 6 hours
02.a urinalysis that is negative for protein
03a urine output of 660 mL in the last 24 hours
04amber-colored urine with a faint odor of ammonia
The nurse is caring for a client with hepatic cirrhosis. Which of the following actions should the nurse take? Click the exhibit button for additional client information.
01.Perform chest physiotherapy on the client.
02. Notify the primary health care provider
03. Perform a bladder scan.
04 Continue with the current plan or care
The nurse is caring for a client with hepatic cirrhosis. Which of the following actions should the nurse take? Click the exhibit button for additional client information
01Perform chest physiotherapy on the client.
02Notify the primary health care provider.
03Perform a bladder scan
04Continue with the current plan or care
The nurse is caring for a client who has a closed-wound drainage system. The nurse observes that the reservoir is completely inflated and there is a small amount of
drainage present. The best action by the nurse would be to
01 empty the reservoir
02. compress the reservoir
03. attach the reservoir to wall suction
04. document the color or the drainage
The nurse is caring for a 4-year-old client with pneumonia. Which of the following therapeutic play activities would be most appropriate for the client?
blowing bubbles
guessing in games In which the client imitates a bird
throwing a soft foam ball
decorating the client’s bed like an airplane
The nurse has received the following information about assigned clients. The nurse should first check the client with
hypothyroidism who is reporting an intolerance to cold
acute pancreatitis who has absent bowel sounds and is reporting vomiting
diabetes mellitus (type 2) who has not had a bowel movement in the past 3 days
coronary artery disease (CAD) whose pulse has changed from 86 to 98 and is reporting nausea
The nurse is caring for a client who had gastric bypass surgery 2 days ago. Which of the following complications should the nurse recognize that the client is at risk of
developing?
Hypertension
pernicious anemia
constipation
diabetes mellitus (type 2)
The nurse is evaluating the effectiveness of the treatment regimen for a client with diabetes mellitus (type 1). Which of the following findings would indicate that the treatment regimen has been eftective?
01. fasting serum glucose level, 8.8 mmol/L
02. glycosylated hemoglobin (HgbA,C), 6.8%
03. postprandial serum glucose level. 10.5 mmol/L
04. total serum cholesterol level. 5.4 mmol/L
The nurse is reinforcing crutch-walking techniques with a client who had a knee arthroscopy 4 hours ago. Which of the following statements by the client would require
follow-up?
“When I am walking. I should support my weight on my axillae
“I will transfer my weight to my arms and unaffected leg before sitting.”
“I will use a 3-point alternating gait so that my affected leg does not touch the ground.”
When I am descending stairs. I should lower the crutches onto the next step before my unaffected leg.’
The nurse is teaching the parents of an 8-month-old client about child safety. Which of the following information should the nurse include? Select all that apply.
“Before placing your child in the crib at bedtime, remove your child’s bib.”
“Position your child’s crib away from the other furniture.
“When the bathroom is not in use. keep the door open
“Place a soft pillow in our child’s crib at bedtime.”
“Avoid wheeled walkers, especially near stairways.”
The nurse is observing a newly hired nurse care for assigned clients. It would require follow-up if the nurse observes the newly hired nurse
01. applying slippers with nonskid soles to the client’s feet before assisting with ambulation
02. adjusting the height of a walker to above the client’s waist
03. measuring the client for crutches by placing the client in the supine position
04. adjusting the length of the client’s cane to allow the elbow to be slightly flexed
The nurse enters the room and observes that a client with atrial fibrillation is having speech difficulties. Which of the following actions should the nurse take first?
Prepare the client for a computed tomography (CT) scan.
Contact the client’s primary health care provider.
Alert the rapid response team.
Check the client’s peripheral venous access device (VAD) for patency.
The nurse is planning a staff education program about time management. Which of the following information should the nurse include?
01 “Avoid using a written schedule to remain flexible to meet clients changing needs
02. “Ask a colleaque to assist with documenting client care.
03. “Make onlv 1 trip to the medication cart to obtain routine medications for all the clients at once
04. Evaluate your assigned tasks to determine which tasks can be assigned to other staff members.”
The nurse has reinforced teaching with the caregiver of a client with moderate Alzheimer’s disease (AD). Which of the following statements by the caregiver would indicate a
correct understanding of the teaching? Select all that apply.
“I should use a lap belt to restrain the client when I need to leave the client’s room.’
“I will ensure that the client wears an identification bracelet at all times.”
“I will make certain the floor is kept clean and free of spills.
“I should keep the room brightly lit and with no glare.”
“I will maintain a regular toileting schedule for the client.”
“I face the client and use short, simple words and phrases when communicating with the client.”
The nurse has received the following information about assigned clients. The nurse should first assess the client who is at
36 weeks gestation and is reporting contractions every 20 minutes
31 weeks gestation and is experiencing painless vaginal bleeding
30 weeks gestation and is scheduled for a nonstress test (NST) because of a history of heart fallure
20 weeks gestation and has vomited 3 times in the past 3 hours
The nurse is planning a community health fair about prevention of traumatic brain injuries. Which of the following clients should the nurse recognize as being at highest risk
tor developing a traumatic brain Injurv?
Q1. the adolescent client who recentlv received a drivers license
02. the older adult client who has grab bars installed in the bathroom
03. the school-age client who is participating in swimming lessons
04. the adult client who wears a helmet while riding a motorcycle
The nurse is preparing a staff education program about spirituality. Which of the following information should the nurse include?
Physical pain often causes spiritual distress for clients
“Spirituality is a personal experience unaffected by cultural context and development.
“Nurses should avoid praying with clients because privacy during prayer is a universal need.”
“Nurses should clearlv state their own beliefs about spirituality when their beliefs differ from the client’s beliefs.”
The nurse is documenting care for a client who is reporting pain. Which of the following would be an example of correct documentation to include in the client’s medical
record?
States, “My right shoulder aches from Iving on my side. ” Rates pain as 3 on a scale of 0 (no pain) to 10 (severe pain). Skin on right shoulder red but blanchable and intact. Repositioned for comfort.
Reports shoulder pain when lying on side. Acetaminophen 650 mg, p.o., administered for pain. Resting now, appears comfortable
Reports increased pain. Rates pain as 3 on a scale of O (no pain) to 10 (severe pain). Primary health care provider notified.
States, “My right shoulder hurts a lot.” Skin normal color and intact. Refused pain medication. Primary health care provider notified
The nurse is prioritizing the following client care activities. Which of the following activities should the nurse perform first:
Obtain a stool specimen to check for ova and parasites from a client who is at 25 weeks gestation and has watery diarrhea.
Assist with collecting a cervical specimen to check fetal fibronectin from a client who is at 33 weeks gestation and has irregular contractions.
Perform a nonstress test (NST) for a client who is at 32 weeks gestation and has gestational diabetes mellitus (GDM).
Check the deep tendon reflexes of a client who is at 37 weeks gestation and feels lethargic while receiving intravenous magnesium sulfate tor preeclampsia.
The nurse is caring for a client and receives a call from another stat member who states, ” My friend has been admitted to your unit. Can you tell me how my friend is
doing?” Which of the following actions should the nurse take:
Give the star member onlv the information available on the admission record.
Forward the call to the client’s room so that a family member can speak with the staff member.
Decline to give the staff member an information about the client’s admission.
Answer all of the staff members questions that are within the staff member’s scope of practice
The nurse is caring for a client who has an order for amikacin 15 mg/kg/day, IV, in 3 divided doses. The client weighs 54.5 kg (120 Ib). The nurse has amikacin 500 mg/100ml available. How many mI should the client receive with each dose? Record vour answer using 1 decimal place
The nurse is teaching a client who is receiving newly prescribed ciprofloxacin. Which of the following information should the nurse include?
“While you are taking the medication, expect to experience a rash that will not resolve until several days after therapy is complete.”
“If you experience Achilles tendon pain, notify your primary health care provider.”
“Take the medication with calcium-fortified orange juice to increase absorption.”
“Limit your fluid intake to 1,000 mL daily.”
The nurse is caring for a client who is receiving prescribed atorvastatin. Which of the following findings would be essential to follow up?
dyspepsia
insomnia
muscle weakness
constipation
The nurse is planning care for a client experiencing atelectasis following surgery. Which of the following interventions should the nurse include in the client’s plan of care?
Monitor the client for apprehension
Assist the client with frequent position changes.
Encourage ambulation
DIscuss advance directives with the client and the clients family
Encourage deep-breathing and coughing
The nurse e is teaching about ways to prevent nipple soreness and injury for a client who is breast-feeding. Which of the following Information should me nurse include
“After each feeding, wash your breasts with soap and water.”
Every 24 hours. change the position your infant assumes for feeding.
“Allow your nipples to air-dry for 10 to 15 minutes after each feeding. ”
When using breast pads, change them frequently.”
*Ensure that your nipple inside our infant’s mouth is back far enough during breast-feeding.”
The nurse is caring for a client with hypoparathyroidism. Which of the following findings would the nurse expect to observe?
tetany
confusion
renal calculi
peptic ulcers
The nurse has attended a staff education program about client confidentiality. Which of the following statements by the nurse would indicate a correct understanding of
program? Select all that apply.
Access to a client’s medical record is limited to health care professionals who are involved in the clients care.
The nurse may share client information with the client’s family members when family members are visiting the client.
The nurse can share client information of a personal nature with other health care professionals
“False statements by the nurse about a client are not considered a violation of the client’s privacy.”
Health care professionals should avoid discussions about clients in public areas or the facility
The nurse has reinforced teaching with the parents of a newborn client about infant abduction in the hospital setting. Which of the following statements by a client indicate a correct understanding of the teaching? Select all that apply.
*Onlv hospital staff wearing the appropriate photo identification are allowed to take my baby out or the room
Walking in the hallway with my baby in my arms is acceptable if I want to ask the nurse a question.
*I must ask hospital staff to match my baby’s identification bracelet to my identification bracelet.
“I will take my babv to the nursery if I wish to take a nap when no family members are present.”
1 should be suspicious if an unknown person who is carrying a large bag or package enters my room.”
*My baby’s crib should be placed on the side of the bed closest to the door.”
The nurse is contributing to a staff education program about physical restraints. Which of the following information should the nurse suggest including
“Secure the restraint ties by using a quick-release knot.”
*Remove the restraints every 3 hours to provide skin care.
*Ensure that 4 fingers can be inserted between a wrist restraint and a client’s wrist.
To apply a vest restraint for a client in a wheelchair, tie the restraints behind the client’s back”
The nurse is caring for a client who sustained a spinal cord injury at L3. The client expresses reluctance to go to a scheduled physical therapy session. Which of the
following would be an appropriate response for the nurse to make?
Tell me why you hesitate to go to physical therapy. It will help you.
“I would like to understand your reservations regarding physical therapy.”
Do you understand that physical therapy will help in your recovery?’
Why are you afraid to go to physical therapy?”
The nurse is caring for a client who has recently experienced the death of a pet. The client states, “I doubt that / will ever recover from the death of my pet * Which of the following responses would be appropriate for the nurse to make?
*I think you should get a new pet as soon as possible in order to help you recover from this loss.
You are unconsciously re-experiencing losses that have occurred earlier in your life.’
*Please tell me why you think this loss is devastating to you.
*I can sit here with you for a while if you would like
The nurse is planning care for a client with Graves’ disease. Which of the following interventions should the nurse include in the client’s plan of care?
Monitor the clients temperature every 4 hour
Provide the client with hot beverages during each meal.
Observe the client for signs and symptoms of hypercalcemia
Place the dent in the supine position at bedtime to reduce pressure behind the eyes
The nurse has reinforced teaching with a 12-year-old client with hemophilia and hemarthrosis. Which of the following statements by the client would indicate understanding of the teaching?
I should apply ice to the affected area
I should ask my parents to call for an ambulance if this happens again
I will make sure my parents buy aspirin on the way home
I will stop performing active range-of-motion (ROM) exercises after the acute episode of injury subsides.
The nurse is caring for a client with schizophrenia. The client states, “Aliens are talking to me through the local news broadcast.” Which of the following would be an
appropriate response for the nurse to make?
“Go to your room, and rest quietly for a while.
Please tell me wat the voices are saying to you
Television news reports are often frightening to near
a will ask your primary health care provider to increase the dose or your medication.
The nurse has attended a staff education program about incident reports. Which of the following statements would indicate a correct understanding of the program? Select
all that apply.
1. “I understand incident reports contain confidential information.
2. I will notify the clients primary health care provider if an incident occurs.”
3. I should complete an incident report if I witness an incident such as a visitors fall.”
4. I will document that an incident report was completed in the client’s medical record.”
5. l understand incident reports are used to improve the quality of health care provided within the institution.”
The nurse is planning a staff education program about evidence-based practice. Which of the
following information should the nurse include? Select all that apply
Evidence-Based practice is based on applying the most relevant and research-based evidence to clinical decision making
Client preferences and values are avoided during integration of evidence-based interventions.
“Evidence-based practice steps begin by questioning current clinical practices.”
The nurse must evaluate the outcome after applying an evidence-based intervention.”
*Published research is robust and flawless.
The nurse is talking with a client who is taking an iron supplement and has constipation. Which of the following statements by the client would be a priority to follow up
“I have a bowel movement only every 2 to 3 days.
“I was incontinent of liquid stool this morning.
*My bowel movements are black in color.
“My stools are the size of small pebbles.”
The nurse is caring for a 2-year-old client with chickenpox. Which of the following infection control precautions should the nurse implement? Select all that apply
Place the client in a private room with monitored negative air pressure.
Wear sterile gloves when assisting the client to eat.
Wear a surgical mask when administering medications to the client
Change gloves after bathing the client.
Advise the dietary department to avoid placing fresh fruit on the client’s meal trays.
The nurse has reinforced teaching with a client who is scheduled for a total vaginal hysterectomy in 24 hours. Which of the following statements by the client would require
follow-up?
I will notify my primary health care provider if I experience redness or pain in my legs after the procedure.
I should avoid lifting heavy objects and having sexual intercourse for several weeks after the procedure. ”
I can expect heavy vaginal bleeding and menstrual cramps alter the procedure
I may experience a loss of vaginal sensation for several months.”
The nurse is reinforcing teaching with a client who is receiving omeprazole. Which of the following information should the nurse reinforce?
Take the medication in the morning before eating breakfast.
“Black. tarry stools are an expected side effect of the medication.”
After taking the medication, remain in an upright position for at least 2 hours.
Avoid consumption of grapefruit and grapefruit juice while taking the medication.
The nurse has reinforced teaching about home safety with the caregiver or a client who has hemiplegia. Which of the following statements by the caregiver would indicate
correct understanding of the teaching?
“I painted the edges of the stairs in our house a bright color.
“I had hand rails installed in the bathtub and next to the toilet.
I have moved all the furniture close together to make it easier to move around the house.”
*I installed a smoke detector in the center of the home so that it can be heard throughout the house.”
The nurse is providing discharge teaching for a client with bipolar I disorder. The client states, Whom should I call when I want my medication plan reviewed?* Which of the following would be an appropriate response for the nurse to make?
“I suggest your call the dietitian, who is familiar with the low-salt diet that has been prescribed.
The case manager assigned to your case will help with your treatment plan.”
Please call your psychiatrist with question about our medication
Your occupational therapist will help you with your treatment plan
The nurse is caring for a client who is at 37 weeks gestation and has proteinuria. Which of the following prenatal conditions would be consistent with the finding of proteinuria?
placenta previa
preeclampsia
oligohydramnios
gestational diabetes mellitus (GDM)
The nurse has participated in a community education program about human sexuality. Which of the following statements by a participant would indicate a correct
understanding of the teaching?
1. Physical strength is reduced on the day following sexual intercourse,
2. “Males become unable to have sexual intercourse after 80 years of age.’
3. Consuming 2 or 3 alcoholic beverages before sexual intercourse can act as a sexual stimulant.”
4. There is no phvsiological contraindication to having sexual intercourse during my menstrual period.
The nurse is contributing to a staff education program about caring for clients with bipolar I disorder who are experiencing a manic episode. Which of the following
information should the nurse suggest including?
The client should be encouraged to take frequent rest periods throughout the day to prevent exhaustion.
The client should be granted all requests immediately to decrease the client’s level of frustration.’
The cent should be encouraged to eat 3 meals daily to maintain proper nutrition
“The client should attend group therapy sessions while in the hospital.
The nurse has attended a staff education program about clients with acute pancreatitis. Which of the following statements by the nurse would require follow-up?
01*Abdominal pain is a symptom for which analgesics are prescribed.”
02 “Hypercalcemia is a common manifestation
03 “Serum amylase and serum lipase levels are obtained as diagnostic tests
04 *Initiallv. the client should be on NPO status.
The nurse is talking with a female client who had a myocardial infarction (MI) and is scheduled for fibrinolytic therapy with alteplase. Which of the following questions would important for the nurse to ask? Select all that applv
“Are you pregnant?”
“Are you currently menstruating!
“Have you had a recent trauma to your head?’
“How much time has passed since our cardiac symptoms began?”
*Are you taking any anticoagulant medications?’
The nurse is talking with the family members of a client who has just died. The family members are crying and comforting each other. Which of the following s
would be appropriate for the nurse to make to the family members?
Everything will be all right’
You will need to take time to heal.”
“I am so sorry for your family’s loss.”
*Your family member is at peace now.”
The nurse is caring for a client who is receiving internal radiation therapy for cervical cancer. Which of the following actions should the nurse take?
Wear sterile gloves when obtaining the client’s vital signs.
Provide the client with a high-fiber between-meal snack.
Limit the client’s fluid in
