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 anxious this morning." As the day shift nurse, going to visit Mr. Sierra to clarify what experience he has had with surgery is an example of which critical thinking attitude?
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 story as well. This is an example of :
The surgical unite has initiated the use of a pain rating scale, which is to be used to assess clients' pain severity during their postoperative recovery. Susan, the RN assigned to Ms. Wills, looks at the pain flow sheet to see Ms. Wills' pain score over the last 24 hrs. Use of the pain scale is an example of which intellectual standard?
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 try it.. After two attempts the client obviously does not understand how to prepare the correct dose. When the nurse returns to the medication room, he discusses the situation with the charge nurse, reviewing his approach with the client and asking for her suggestions on his technique. This is an example of:
Basic Critical thinking
A nurse uses and institution's procedure manual to confirm ho to insert a foley catheter. the level of critical thinking the nurse is using is:
A client has hip surgery 24 hrs ago. The nurse refers to the written plan of care, noting that the client has a drainage device collecting wound drainage. The health care provider is to be notified when drainage in the device exceeds 100mL for the day. when the nurse enters the room, the nurse looks at the device and carefully notes the amount of drainage currently in the device. This is an example of:
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 component involved in the nurse's review of the literature is:
I will make sure that I eat a balanced diet and exercise regularly
You are teaching a client about healthy nutrition. You recognize that the client understands the teaching when he states:
As a nurse, you teach a client who has had surgery to increase which nutrient to help with tissue repair
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
You are caring for a client experiencing dysphagia. Which interventions will help decrease the risk of aspiration during feeding?
Turn client to left lateral decubitus position
The nurse suspects that the client receiving PN through CVC has and air embolus. What action doe the nurse need to take first?
Place an order for x-ray examination to check position
Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube?
Based on knowledge of peptic ulcer disease, the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a client suspected of having PUD?
Gastric residual aspirate of 300mL for the 2nd consecutive time
You are assessing a client receiving enteral feedings via a small-bore NG tube. Which assessment findings need further intervention?
A recently widowed 76-year old woman recovering from a mild stroke
The home care nurse is seeing the following clients. Which client is at greatest risk for experiencing inadequate nutrition?
A female client reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is:
The urine appears concentrated and cloudy because of the presence of white blood cells or :
Urinary tract infection
Elimination changes that result form obstruction to the flow of urine in the urinary collecting system may cause which of the following?
Improper catheter care
Health care acquired UTIs are often related to poor hand washing and:
Bright orange to rust
Some medications change the color of urine. Pyridium colors the urine:
2 hrs before bedtime
To minimize nocturia, clients should avoid fluids:
Maintaining a foley catheter drainage bag in the dependent position prevents:
Snug and secure, but does not cause constriction to blood flow
When applying a condom catheter, it is important to secure the catheter on the penile shaft in such a manner that the catheter is:
1320 mL for the 8 hr period
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 and 8-hr period. How much of the total is urine output?
That there are no special precautions
A client undergoes a kidney ultrasound examination. The nurse providing post procedure care remembers:
A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes
A nursing diagnosis is:
Making a diagnostic statement
Lisa reviews data she has regarding Ms. Devine's pain symptoms. She compares the defining characteristics for acute pain with those for chronic pain. In the end she selects acute pain as the correct diagnosis. This is an example of Lisa avoiding an error in:
Facilitate understanding of client problems among health care providers
One of the purposes of the use of standard formal nursing diagnostic statement is to:
Wellness nursing diagnosis
The nursing diagnosis readiness for enhanced communication is and example of a:
Actual nursing diagnosis
The nursing diagnosis hypothermia is an example of an:
The word impaired in the diagnosis Impaired physical mobility is and example of a
The nurse assessing the edema in a client's lower leg is unsure of its severity and asks a co-workers to check it with him or her.
What nurse act is to avoid a data collection error?
"Unhappy and worried about health" is not a scientifically based nursing diagnosis, and it can lead to error in:
Identifying the medical diagnosis instead of the client's response to the diagnosis
Clase is reviewing a client's list of nursing diagnoses in the medical record. The most nursing diagnosis is diarrhea related to intestinal colitis. this is an incorrectly stated diagnostic statement, best described as:
Which of the following are defining characteristics for the nursing diagnosis impaired urinary elimination?
Call the physician to have the order clarified
The nurse is having difficulty reading a physician's order for medication. The nurse knows the physician is very busy and does not liked to be called. The nurse should
The client has an order for 2 tablespoons of Milk of Magnesia. The nurse converts this dose to the metric system and gives the client:
Fails to follow routine procedures
Most medication errors occur when the nurse:
A client is to receive cephalexin (Keflex) 500mg PO. The pharmacy has sent 250-mg tablets. The nurse gives:
Investigate the client's mental status before administering any further medication
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 states still another name. What is the nurse's next action?
Ensure the home care agency is aware of medication and health teaching needs.
A client is transitioning form 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?
The name of the medication and a description of its desired effect
A nursing student takes a client's antibiotic to his room. The client asks the nursing student what it is and why he should take it. The nursing student's reply includes the following information:
Ask the physician to change the order
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 client's reason for refusal
The nurse takes a medication to a client, and the client tells the nurse to take it away, because she is not going to take it. The nurse's first action should be to:
The prescriber's order
The nurse selects the route for administering medication according to:
Follow facility policy or drug manufacturer's direction
A client is receiving an IV push medication. If this type of drug infiltrates into the out tissues, the nurse will:
If a client who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects :
Chronic back pain and arthritis
Nurses can educate clients about the benefits of complementary therapies. Clients with which of the following might find relief in complementary therapies?
Breathwork and imagery
Some complementary therapies, such as acupuncture, contain diagnostic and therapeutic methods specific to their field, whereas others, such as the following are more easily learned and applied:
Exceed the visits to allopathics
It is estimated that half of U.S. citizens use CAM practitioner and that these visit
Mind, body and spirit of client
Holistic nursing regards and treats the:
Permission is a prerequisite for implementation
In addition to the necessity for adequate assessment, when the nurse utilizes CAM the client's:
Actively involved in the treatment
One of the principles of CAM therapies is that the individual becomes:
Protects an individual from harm
The stress response is good example of the way in which systems:
Antihypertensive and thyroid-regulating medications
Clients' medications should be monitored carefully because medication may augment the effects of certain drugs such as:
In learning how to control specific autonomic nervous system response
Biofeedback techniques are frequently used in addition to relaxation to assist individuals:
Therapeutic touch is a training specific therapy that was developed by a
The client expresses concern about pain control
The client's vital signs change, showing a drop in blood pressure
Sheila is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment Sheila anticipates the need to monitor the client's abdominal dressing, IV infusion, and function of drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. Sheila will have to establish priorities of care in which of the following situations?
Reconnect the drainage tubing
Sheila's client signals with her call light. Sheild enters the room and finds the drainage tube disconnected, the IV has 100 ml of fluid remaining, and the client has asked to be turned. Which of the following should Sheila perform first?
Client will remain afebrile until discharge
In her nursing care plan, Sheila enters expected outcomes for her client. Which of the following expected outcomes are written correctly?
Indicate when the client is expected to respond in the desired manner
Sheila set a time limit for her outcomes. The time frame serves to:
Client's highest possible level of wellness and independence in function
A client-centered a goal is a specific and measurable behavior or response that reflects a:
Client will report pain acuity less than 4 on a scale of 0 to 10
The nurse writes and expected out come statement in measurable terms. An example is:
Provide frequent mouth care
Control aversive odors or unpleasant visual stimulation that trigger nausea
Sheila's client is experiencing nausea and abdominal distention postoperatively. Sheila initiates the interventions listed below. Which of the interventions are examples of independent interventions?
Multiple health care professionals
Collaborative interventions are therapies that require:
After the care plan has been developed
When does implementation begin as the fourth step of the nursing process?
Indirect care measure
Mr. Switzer is 34 years old client who had a surgical repair of an abdominal hernia this morning. At 12 noon the nurse records Mr. Switzer's vital signs on the recovery room flow sheet. the recording of vital signs is an example of:
Reviewing possible consequences of a nursing action
Before beginning insertion of a client's indwelling urinary catheter, the nurse considers the steps to take to avoid the possibility of breaking sterol technique, which could cause a urinary infection. This is an example of what type of decision making?
Contributions of all disciplines caring for the client
Interdisciplinary care plans represent:
Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following?
Showing confidence in knowing which dressing materials to use
In which of the following examples is a nurse applying critical thinking attributes when performing a dressing change?
Seek necessary knowledge
Reassess the client's condition
Collect all equipment necessary
Have and experienced nurse available to assist
Consider all possible consequences of the procedure
Which steps do you follow when you are asked to perform a procedure with which you are unfamiliar?
Auscultating lungs sounds
A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides a glass of water for the client. Which of the following is an evaluative measure used by the nurse
Client's lungs are clear to auscultation is bases
Client's rate and depth of breathing are normal with head of bed elevated
A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides a glass of water for the client. Which of the following is an appropriate evaluative criterion used by the nurse?
Matching the results of evaluative measures with expected outcomes to determine client's status
The evaluation process, which determines the effectiveness of nursing care, includes five elements, one being interpreting findings. Which of the following is an example of interpretation?
Resolution of a nursing diagnosis or maintenance of a healthy state
A goal specifies the expected behavior or response that indicates:
Client's wound will remain free of infection by discharge
A client is recovering from surgery fro removal of an ovarian tumor. It is one day after her surgery. Because she has an abdominal incision and dressing, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis?
Unmet and partially met goals require the nurse to do which of the following?
Increase life expectancy and quality of life and to eliminate health disparities
The overall goal of healthy people 2010 is to:
Teaching the community about illnesses
Improving the health care of the community's children
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 with the community leaders and explain the need for immunizations, the location of the clinic, and the process of accessing health care resources. Which of the following practices are you providing?
Public health sciences
Community health nursing is a nursing approach that merges knowledge form which of the following professional nursing theories?
Excess risks, limits in access to health care services, and dependency on others for care
Vulnerable populations of clients are those who are more likely to develop health problems as a result of:
Acute and chronic physical illnesses
Which of the following are major public health problems commonly affecting older adults
The local health department received information for the Centers of Disease Control and Prevention that the flu was expected to be very contagious this season. You are asked to set a flu vaccine clinics in local churches and senior citizen centers. This activity is an example of which level of prevention?
The local school has an increasing number of adolescent parents, and you work with school district to design and teach classes about infant care, child safety, and time management. These are examples of which nursing role?
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:
Lisa tried the insulin pump on a limited basis
Lisa views use of the insulting 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 more advantageous than other alternatives to insulin administration
In you community clinic you care for Lisa, a 40 year old women 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 the disease. Which of the following change gactos in crease the likelihood that she will accept this new insulting pump?
Structure or locale, people, and social systems
What are the three elements that are included in community assessment?
Reapplying a condom catheter for a client who has urinary incontinence
A nurse on a medical-surgical unit has received change-of-shift report and has been assigned to care for four clients. Which of the following client's needs may be assigned to an assistive personnel?
The client is in room 203 bed-b
The client ambulates with his slippers on over his anti embolic stockings.
The client uses a front-wheeled walker when ambulating
The client had pain medication 30 mins ago
The client should ambulate 50 ft at least
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
Replacing the cartridge and tubing on a PCA pump
An RN is making assignments for client care to LPN at the beginning of the shift. What should the LPN question?
Respiratory rate of 22/min with respirations that are even and unlabored
"I can only walk three blocks before amy leg starts to hurt."
Pain rated at 3 on scale of 0 to 10
Skin pink, warm, and dry
Urine output of 300 mL/8hr
"My wife doesn't come to visit very often
Dressing clean, drum and intact
Reassess the client to determine the reason satisfactory pain relief has not been achieved
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next based on the nurse process?
Id whether or not the client outcomes have been met
During evaluation, the nurse must gather information about the client to :
Give morphine sulfate 1 to 2 mg IV every 1 hr as needed for pain
Insert a NG tube
Apply moist heat to left arm
Listen actively to client's concerns
Perform daily bath after even meal
Infuse 0.9% sodium chloride at 125 mL/hr
A client is experiencing hypertension, and the provider prescribes a newly approved antihypertensive medication. Prior to administering the medication, the nurse gathers information about the medication using an electronic database. The nurse is using which of the following components of critical thinking reviewing the medication information?
A nurse receives a prescription for an antibiotic for 35-year-old man who has cellulitis. The nurse checks the client's chart, discovers that the client is allergic to the antibiotic, and phones the provider to obtain a prescription for a different antibiotic. What critical thinking attitude did the nurse exhibit?
A nurse offers to put an IV catheter in a client who is dehydrated
A nurse uses a head to toe approach to conduct a physical assessment
A nurse tries three different pouches before finding one that will contain the draining wound
A nurse mistakenly give the wrong does of medication to a client. The nurse calls the provider to notify her of the error.
A nurse states that she has difficulties inserting IV catheters in clients who are dehydrated.
Which of the following is primary source for client data during the admission process?
Orient the client to his room
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?
The time received and the amount of the last pain medication dose
When transferring a client with a fractured radius from the emergency department to the orthopedic unit, which of the following information should the nurse include in the transfer report?
The client is alert and oriented
The client has an allergy to shellfish
The client needs morphine every 4 hours
What should be included int a transfer report?
Nurse transferring the client
Who is responsible for making sure all documentation is finished prior to transfer of a client to a new health care facility?
When the client is admitted
When does discharge planning begin in an acute care facility?
Where the client needs to go for follow-up care
Instructions given on medication and treatments
Summary of the client's condition at time of discharge
The phone number of the home health agency that will be making home visits
What data should be included in a client's discharge summary?
Instruct the client to touch her chin when swallowing
A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention?
Which of the following nutrients is the body's preferred energy source?
If their diets are not adequately supervised, school-age children tend to have dietary deficiencies in what?
What is appropriate for a nurse to give a client who is on a low-residue diet?
Offer information and asks the client if he is interested in trying a relaxation technique
A nurse admits a client for abdominal surgery. The client's initial vital signs are temp 37 C (98.6 F), pulse 98/min, respirations 20/ min, and blood pressure 138/88 mm Hg. The client states, "I am really worried . This the first surgery I have ever had." Which of the following is an appropriate use of complementary alternative intervention?
"Chiropractors use their hands to manipulate the spine to treat back pain."
A nurse is caring for a client who reports back pain and tells the nurse that a friend has recommended a chiropractor. She asks the nurse what a chiropractor does to relieve back pain. Which of the following response by the nurse is correct?
Massage therapy is an example of which category of alternative therapy?
Within the scope of nursing practice
Addition certification or license required
Within the scope of nursing practice
Addition certification or license required
Addition certification or license required
Within the scope of nursing practice
Check to see if the catheter is patent
A client with an indwelling catheter reports a need to urinate. Which of the following interventions should the nurse perform?
Discard the first voiding
Which of the following nursing interventions is correct when performing a 24 hr urine specimen test?
Which of the following position promotes a client's normal elimination?
Maintain surgical asepsis throughout the procedure
Position the client supine with knees bent apart
Which of the following interventions is appropriate when performs a catheterization of a female client?
Mimic the action of the body's own hormones
Block the action of the body's own compounds
When medications act on receptors the can dow which of the following?
After an oral medication has been absorbed, most of the medication is inactivated as the blood initally passes through the liver, producing little therapeutic effect. This is called:
Intravenous administration of medication eliminates the need for:
Sitting, semi-fowler's, or fowler's position
Client lying on side with the eat that is receiving the drops facing up
Supine with the knees bent, the feet flat on the bed and close to the hips
lying of the left side with the right knee brought up toward the chest (sim's position)
A tuberculin syringe with a fine-gauged needle (26-27)
A short, fine-gauge needle (3/8 to 5/8 inch, 25 to 27 gauge)
needle size 18 to 27 (1 to 1 1/2 inch, 22 to 25 gauge)
16 to 24 gauge catheters appropriate for most adults , smaller gauge catheters appropriate for infants and children
held under the tongue until dissolved
Nitroglycerin (Nitrogard) tablets, which are often prescribed for clients who have cardiovascular disorders, are give sublingually. This means that the tablets are
Offer to assist the client needing the bedpan
A nurse prepares an injection of morphine (Duramorph) to five to a client who reports pain. Prior to minister the medication, the nurse is called to another room to assist another client onto a bedpan. This nurse asks a second nurse to give the injection so that she can help the client need the bed pain. Which of the following action should the second nurse take?
For a medication that was ordered at 0900, which of the following are acceptable administration times?
Checking with the provider when a single dose requires administration of multiple tablets
Which of the following nursing actions may prevent medication error?
Observing for medication side effects
Monitoring for therapeutic effects
Maintaining an up-to-date knowledge base
When implementing medication therapy, the nurse's responsibilities include which of the following?
Id client allergies
Determine client outcome
Follow the six rights of medication administration consistently
Recognize side/adverse effects
A drop in temperature around the site
Local selling at the site
A damp dressing
When assessing the IV site for infiltration, the nurse should look for which of the following findings?
The date and time of insertion
The insertion site and appearance
The catheter size
The type of dressing
The IV fluid and rate (if applicable)
The number, location, and conditions of the site-attempted cannulations
What information should the nurse include when documenting the insertion of an IV catheter?
trauma clients, rapid fluid volume
surgical client's, rapid blood administration
22 to 24 gauge
Children, older adults, and stable postoperative clients
Shortness of breath
Crackles heard in the lungs
A nurse in caring for a client receiving dextrose 5% in IV water at 100 mL/hr. Which of the following should the nurse observe for when assessing for fluid overload?
Two medications cause drowsiness
A nurse has just been assigned to a newly admitted client. When the nurse checks the medication administration record, she observes that the client is taking four medications. What should concern the nurse?
Keep a bottle of water availableWear sunglasses when exposed to sunlight
Urinate prior to taking the medication
A nurse informs a client that a prescribed medication may have side effects. Which of the following instructions should the nurse give if anticholingeric effects are among the potential side effects?
Delay clearance of medications from the blood
A nurse is caring for a client who has renal damage secondary to glomerulonephritis. Which of the following should the nurse monitor when administering the client's medications?
Consult the provider prior to taking OTC medications
A client has been recently diagnosed with hypertension and prescribed an antihypertensive medication. Which of the following instructions should the nurse give to the client in regard to taking OTC medications?
Place pills in daily pill holders
Contact the provider if side effects occur
Ask a relative to assist periodically
A nurse is providing teaching to an older adult client to promote adherence with medication administration. Which of the following instructions would be included?
A nurse is caring for a client who says that his pain medication is not working like it used to the nurse should recognize that the client is experiencing:
Lower blood pressure
higher body water content
Increase absorption of topical medications
A nurse is preparing medications for a preschool child. Which of the following factors should the nurse recognize as altering how a preschool child is affected by medication?
Which of the following formulas is nutritionally complete?
The enteral access tube best suited for short-term use (less than four weeks) is a:
Clear the tubing to prevent clogging
The purpose of flushing a tube after an enteral feeding is given tis to:
That the tube is correctly placed
The highest priority nursing assessment before initiating an enteral feeding is determining:
Stop the feeding
A nurse is caring for a client receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority if aspiration of tube feeding is suspected?
Tape from the client's nose to the NG tube
The proper way to secure a nasogastric tube is to apply:
Comparing data with normal health patterns
A 46-year-old client is seen at the family practice office for a yearly physical examination. In evaluating the client's weight, the nurse also considers the age and height. This is an example of:
Assess the client and, if unsure of the finding, ask the faulting to assess the client
In order for a student to avoid a data collection error the student should:
The school nurse suspects that a junior high school student may have anorexia nervosa. This eating disorder is characterized by:
Check to see that the tube is properly placed
You receive an order to begin enteral tube feedings. The first step you must take is to:
"I am making eating choices according to the recommended dietary allowance intakes."
A 22-year old new mother is breast feeding. You ask her if she is taking in the correct amount of nutrients. You know the young mother understand the dietary guidelines when she states:
All clients waiting for a kidney transplant have to meet the same qualifications
A client decides not to have open heart surgery despite significant blockages
A nurse offers pain medication to a client who is postoperative prior to ambulation
A nurse questions a medication prescription as being too extreme in light of the client's advanced age and unstable condition
A nurse takes a client outdoors pin a wheelchair after lunch as promised