Nursing 140 Final
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tfulcherpowell on December 9, 2011
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Terms | Definitions |
|---|---|
| During an initial interview the client makes this statement, I'm really not that sick or in pain right now. The nurses best response is: a) It's ok to be worried surgery is a big step b) What kind of questions do you have about your surgery c) I think these are things you should be asking your doctor d) have you had surgery before |  B) What kind of questions do you have about your surgery |
| A client is hospitialized with numerous acute health problems. According to Maslow's Basic needs model, which nursing diagnosis would take the highest priority: a) Risk for injury related to unsteady gait b) Altered nutrition, less than body requirements related to inability to absorb nutrients c) Self-care deficit related to weakness and debilitation d) Powerlessness related to chronic disease state | B) Altered nutrition, less than body requirements related to inability to absorb nutrients |
| When reviewing both the client's problem list against the various identified nursing diagnoses, both of which include client and family input, the nurse is utilizing of the following processes to minimize diagnostic error: a) Understanding what is normal vs. what is not normal b) Verifying c) Consulting resources d) Basing diagnoses on patterns | B) Verifying |
| The client is admitted to a comprehensive rehabilitation center for continuing care,following a motor vehicle crash. While the admitting nurse will develop the initial care who will be involved with the ongoing planning of this client's care: a) The admitting nurse continues to assume that responsibility b) All nurses who work with the client c) Everybody involved in the client's care d) The client and the client's support system | C) Everybody involved in the client's care |
| The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse's states, "This is not normal behavior". The nurse documents this is which of the following: a) inference b) Subjective data c) Objective data d) Secondary subjective | C) Objective data |
| The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process: a) Assessment b) Diagnoses c) Implementation d) Evaluation | a) Assessment |
| A client is attending classes on building positive relationships with significant others as well as learning skills to be open minded and respectful to those whose opinions are different. This client is focusing on which component of wellness: a) Physical b) Social c) Emotional d) Environment | B) Social |
| An example of correctly written nursing diagnoses statement is: a) Altered tissue perfussion related to heart failure b) Risk for impaired tissue integrity related to sacrel redness c) Ineffective coping related to response to biopsy test results d) Altered urinary elimination related to urinary tract infection | C) Ineffective coping related to response to biopsy test results |
| Which would be an expected outcome for a client with the following nursing diagnoses self-care deficit related to congnitive impairment: a) The client will be able to name the staff that works on the day shift b) The client will eliminate safety hazards in her environment c) The nurse will stress the importance of adequate fluid intake d) The client with supervision will brush her teeth | D) The client with supervision will brush her teeth |
| The nurse has admitted a patient with a new diagnoses of pneumonia and explained to the patient that together they will plan the patient's care and set goals for discharge. The patient says, "How is that different from what the doctor does?" Which response by the nurse is most appropriate: c) Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors d) In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health | D) In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health |
| A 43 year old is diagnosed with type 2 diabetes mellitus after being admitted to the hospital with an infected foot wound. When applying principles of adult learning, which teaching strategy by the nurse is most likely to be effective: a) Discuss the importance of blood glucose control in maintenance of long term health b) Demonstrate the correct method for cleaning and redressing the wound to the patient c) Assure the patient that the nurse is an expert on management of diabetes complications | B) Demonstrate the correct method for cleaning and redressing the wound to the patient |
| A nursing activity that is carried out during the evaluation phase of the nursing process is: a) Determining if interventions have been effective in meeting patient's outcome b) Documenting the nursing care plan in the progress notes in the medical record c) Deciding whether the patient's health problems have been completely resolved d) Asking the patient to evaluate whether the nursing care provided was satifactory | A) Determining if interventions have been effective in meeting patient's outcomes |
| The nurse is preparing written handouts to be used as part of the standardized teaching plan for patient's who have been recently diagnosed with diabetes. Which of the following statements would be appropriate to include in the handouts: a) Polyphagia, polydipsia, and polyuria are common symptoms of Diabetes mellitus b) The use of the right foods can help in keeping blood glucose at a near-normal level c) Some diabetes control blood glucose with oral medications or nutritional interventions d) Diabetes mellitus is characterized by chronic hyperglycemia and the associated symptoms | B) The use of the right foods can help in keeping blood glucose at a near-normal level |
| The nurse primarily uses the nursing process in the care of patient's: a) To explain nursing interventions to other health care professionals b) As a problem solving tool to identify and treat patient's health care problems c) As a scientific based process of diagnosing the patient's health care problems d) To establish nursing theory that incorporates the biopsychosocial nature of humans | B) As a problem solving tool to identify and treat patient's health care needs |
| When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes the part of the purpose of the nursing process is to: a) Deliver care to a client in an organized way b) Implement a plan that is close to the medical model c) Identify client needs and deliver care to meet those needs d) Make sure that standardized care is available to clients | C) Identify client needs and deliver care to meet those needs |
| Which nursing diagnoses would the nurse use for a client prone to falls: a) Deficient knowledge b) Risk for Injury c) Risk for disuse syndrome d) Risk for suffocation | B) Risk for Injury |
| A client tells the nurse that she does not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do? a) Assign UAP the task of giving the client's bath b) ASk the client the usual way bathing occurs at home c) Skipping the patient's bath and documenting "refused" is not following at client-centered approach d) Tell the client that a bath is needed and ignore the client's comment | B) Ask the client the usual way bathing occurs at home |
| The nurse case manager is concerned about A particular client being discharged from the hospital. Which of the following factors, if present for this client, would alert the nurse to possible problems with treatment adhearance: a) The prescribed therapy is costly and of unknown duration b) The therapy will require no lifestyle changes of the client c) The client has not had difficulty understanding the regimen d) The client's culture is supportive of Western medicine | A) The prescribed therapy is costly and of unknown duration |
| When admitting a patient who has just Arrived on the medical unit with severe abdominal pain, what should the nurse do first: A) Complete only basic demographics data before addressing the patient's abdominal pain b) Medicate the patient for the abdominal pain before attending to the health history and examination c) Inform the patient that the abdominal pain will be treated as soon as the health history is completed d) Take the initial vital signs and then deal with the abdominal pain before completing the health history | D) Take the initial vital signs and then deal with the abdominal pain before completing the health history |
| A patient who is having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to: a) Obtain subjective data about the patient's family membrane b) Omit subjective data collection and obtain the physical examination c) Use the health care provider's medical history to obtain subjective data d) Schedule several short sessions with the patient to gather subjective data | D) Schedule several short sessions with the patient to gather subjective data |
| A nurse is practicing the concept of holism to the client. Which of the following is the best example of this: a) The nurse considers how the loss of a client's job will affect the regulation of the client's diabetes b) The nurse makes sure to do a complete teaching regarding pharmacological interventions c) The nurse is careful to follow physician treatments on schedule d) The nurse is able to prioritize the needs of the client assigned according to Maslow's hierarchy | A) The nurse consider's how the loss of a client's job will affect the regulation of the client's diabetes |
| A nurse is providing a back rub to a client just after administering a pain medication, with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing: a) Assessment b) Diagnosis c) Implementation d) Evaluation | C) Implementation |
| A client just had a baby following a long labor and difficult delivery. Which of the following nursing diagnoses is formulated correctly: a) Constipation, due to tissue trauma, manifested by no bowel movements for two days b) Risk for infection, because of new incision, related to episiotomy c) Ineffective breast feeding, related to lack of motivation, secondary to exhaustion d) Altered urinary elimination, secondary to childbirth | C) Ineffective breast feeding, related to lack of motivation, secondary to exhaustion |
| One of the client's assigned to the nurse's care is to receive a medication that the nurse is not familiar with and is not not listed in the drug reference manual. The best action of the nurse is to: a) Follow the physician's order as written and give the medication b) Call the pharmacy and do further investigating before administering the medication c) Ask the client about this medication d) Call the physician and ask what the medication is and what it is used for | B) Call the pharmacy and do further investigating before administering the medication |
| A student nurse who claims to be very uncreative and dose not understand why it is necessary to assess and develop new ideas in the clinical area. The best response by the nurse educator is: a) Creativity allows unique solutions to unique problems b) Not all your answers are going to be from your textbook c) Creativity makes nursing fun d) You'll get bored if you don't learn to be creative | A) Creativity allows unique solutions to unique problems |
| A community health nurse is testing the theory of locus of control (LOC). Which of the following client's demonstrates the internal control concept of this theory: a) A client who takes an active role in all health decisions b) A client who allows the primary care provider to make all the decisions c) A client who does not make any decisions without his/her souse's input d) A client who relies on information from the local hospital for his.her health needs | A) A client who takes an active role in all health decisions |
| Wanting to know more about the client's pain experience, the nurse continues to explore different questioning techniques. Which of the following is the best example of an open-ended question for this situation: a) Is your pain worse at night b) What brought you to the clinic c) How has the pain impacted your life d) You're feeling down about having pain, aren't you | C) How has the pain impacted your life |
| When the nurse is planning for the physical examination of an alert 86 year old patient. Adaptions to the examination technique should include: a) Speaking slowly when directing the patient b) Avoiding the use of touch as much as possible c) Using slightly more pressure for palpation of the liver d) Organizing the sequence to minimize position changes | D) Organizing the sequence to minimize position changes |
| A client has been having pain without any clear pathology for cause. The most appropriately written nursing diagnoses for this client would be which of the following: a) Pain due to unknown factors b) Pain related to unknown etiology c) Pain caused by psychosomatic condition d) Pain manifested by client's report | B) Pain related to unknown etiology |
| A patient with a stroke is paralyzed on the left side of the body and has developed a pressure ulcer on the left hip. The best nursing diagnoses for this patient is: a) Impaired physical mobility related to left-sided paralysis b) Risk for impaired tissue integrity related to left-sided weakness c) Impaired skin integrity related to altered circulation and pressure d) Ineffective tissue perfusion related to inability to move independently | C) Impaired skin integrity related to altered circulation and pressure |
| After the nurse implements diet instructions for a patient with heart disease the patient can explain the information but fails to make recommended dietary changes. The nurse's evaluations that: a) Learning did not occur because the patient's behavior did not change b) Choosing not to follow the diet is the behaviors that resulted from learning c) The nursing responsibility for helping the patient make dietary changes has been fulfilled d) The teaching methods were ineffective in helping the patient learn the dietary information | B) Choosing not to follow the diet is the behaviors that resulted from learning |
| A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has the following diagnoses: anxiety related to unfamiliarity of disease process, manifested by restlessness tachycardia. The etiology of this diagnoses is which of the following: a) Unfamiliarity of disease process b) Anxiety c) Restlessness d) Tachycardia | A) Unfamiliarity of disease process |
| While admitting a patient to the medical unit, the nurse learns that the patient does not read well. This information will guide the nurse in determining: a) The degree of patient motivation and readiness to learn b) What information the patient will be able to understand c) That the family must be included in the teaching process d) Which instructional strategies should be used in teaching | D) Which instructional strategies should be used in teaching |
| Nurses must use critical thinking in their day-to-day-practice, especially in circumstances surrounding client care and wise use of resources. In which of the following situations would critical thinking be most beneficial: a) Administering IV push medications to critically ill patients b) Educating a home health patient about treatment options c) teaching a new parent car seat safety d) Assisting an orthopedic client with the proper use of crutches | B) Educating a home health patient about treatment options |
| On one of the first days working alone, the novice nurse must provide teaching on tracheotomy care to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to: a) ASk the nurse mentor to assist with the teaching after reviewing the procedure b) Read the policy and procedure manual before the teaching session c) Do the best the nurse can by remembering what was taught in nursing school d) ASk for a different assignment until the nurse feels comfortable with this one | A) ASk the nurse mentor to assist with the teaching after reviewing the procedure |
| A patient who has been admitted to the hospital for surgery tells the nurse, 'I do not feel right about leaving my children with my neighbor", which action should the nurse take next: a) Reassure the patient that these feelings are common for parents b) Have the patient call the children to ensure that they are doing well c) Call the neighbor to determine whether adequate childcare is being provided d) Gather more data about the patient's feeling about the child-care arrangements | D) Gather more data about the patient's feeling about the child-care arrangements |
| A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBC)s and a shift to the left. The nurse anticipates that the next action will be to: a) Obtain wound cultures b) start antibiotic c) Reddress the wound with wet-to-dry dressing d) Continue to monitor the wound for purulent drainage | A) Obtain wound cultures |
| The nurse has just received change-of-shift report about the following four patients which patient will the nurse assess first: a) The patient who has multiple black wounds on the feet and ankles b) The newly admitted patient with a stage IV pressure ulcer on the coccyx c) The patient who needs to be medicated with multiple analgesics before a scheduled dressing change d) The patient who has been receiving immunosuppressants medications and has a temp of 102' F | D) The patient who has been receiving immunosuppressants medications and has a temp of 102' F |
| Which action can the nurse delegate to nursing assistive personnel (NAP) who help with treatment of a patient admitted with tuberculosis and placed on airborne precautions: a) Teach the patient about how to use tissues to dispose of respiratory secretions b) Stock the patients room with all necessary personal protective equipment c) Interview the patient to obtain the names of family members and close contacts d) tell the patient's family members the reason for the use of airborne precautions | B) Stock the patient's room with all the necessary personal protective equipment |
| A patient is taking a potassium-wasting diurectic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as: a) personality change b) Frequent loose stools c) Facial muscle spasms d) Generalized weakness | D) Generalized weakness |
| A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaCO@ 32 mmttg, and HCO 25 mEq/L. The nurse interprets these results as: a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis | D) Respiratory Alkalosis |
| A patient has the following arterial blood gas (ABG) results: ph 7.32, PAO2 88 mmHg, PaCO@ and HCO3 16 mEqL. The nurse interprets these results as: a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis | A) Metabolic Acidosis |
| A patient who has just been started on continuous tube feedings of a full strength commercial formula at 100 mL/hr using a closed system method has six diarrhea stools the first day. What action should the nurse plan to take: a) Slow the infusion rate of the tube feeding b) Check the gastric residual volumes more frequently c) Change the internal feeding system and formula every 8 hrs d) Discontinue administration of water through the feeding tube | A) Slow the infusion rate of the tube feeding |
| A patient who has a wound infection after major surgery has only been taking in about 50% to 75% of the ordered meals and states, "Nothing on the menu really appeals to me." Which action by the nurse will be most effective in improving the patient's oral intake: a) Make a referral to the dietician d) Have family members bring in favorite foods from home | D) Have family members bring in favorite foods from home |
| The nurse is performing an admission assessment on a 20 year old college student who is being admitted for electrolyte disorders of unknown etiology. Which assessment is most important to report to the health care provider: c) The patient has history of weight fluctuations d) The patient's serum potassium level is 2.9 mEq/L | D) The patient's serum potassium level is 2.9 mEq/L |
| Which of these nursing actions included in the plan of care for a patient who is receiving intermittent tube feedings through a percutaneous endoscopic gastrostomy )PEG) tube may be delegated to an LPN/LVN: a) Providing skin care to the area around the tube site b) Assessing the patient's nutritional status at least weekly | A) Providing skin care to the area around the tube site |
| When preparing to teach an 82 year old Hispanic patient who lives with an adult daughter ways to improve nutrition, which action should the nurse take first: a) Ask the daughter about the patient's food preference b) Determine who shops for groceries and prepare meals | B) Determine who shops for groceries and prepare meals |
| All of the following nursing actions are included in the plan of care for the patient who is malnourished. Which action is appropriate for the nurse to delegate to nursing assistive personnel (NAP): c) Offer the patient the prescribed nutritional supplement between meals d) Assess the patient's strength while ambulating the patient in the room | C) Offer the patient the prescribed nutritional supplement between meals |
| The nurse is developing a weight loss plan for a 21 year old patient who is morbidly obese. Which statement by the nurse is most likely to help the patient in loosing weight on the planned 1000 calorie diet: c) Most of the weight that you lose during the first weeks of dieting is water weight rather than fat d) You are likely to start to notice changes in how you feel with just a few weeks of diet and exercise | D) You are likely to start to notice changes in how you feel with just a few weeks of diet and exercise |
| In planning preoperative teaching for a patient undergoing a Roux-en y gastric bypass as treatment for morbid obesity the nurse places the highest priority on: b) Discussing the necessary postoperative modifications in lifestyle c) Teaching the patient proper coughing and deep breathing techniques | C) Teaching the patient proper coughing and deep breathing techniques |
| The mother of a 1 month old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instructions should the nurse give this infants mother: a) Have the infant be seen by a physician b) Give the infant at least 2 ounces of juice every 2 hours | A) Have the infant be seen by a physician |
| The nurse is caring for an 80 year old patient with the medical diagnosis of heart failure. The patient has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client: c) Excess fluid volume related to retension of fluids as evidence by edema and orthopnea d) Excess fluid volume related to cognitive heart failure as evidence by edema and confusion | C) Excess fluid volume related to retension of fluids as evidence by edema and orthopnea |
| An older patient receiving intravenous fluids at 175 mL/HR is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy: b) Fluid volume excess c) Pulmonary embolism | B) Fluid volume excess |
| The nurse assesses an open area over a patient's greater trochanted that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional findings would indicate to the nurse that this is a Stage IV pressure ulcer: b) The crater extends into the subcutaneous tissue c) The joint capsule of the hip is visable | C) The joint capsule of the hip is visable |
| The client has a documented Stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client: c) Impaired tissue integrity d) Risk for Injury | C) Impaired Tissue Integrity |
| The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin: b) Coat the patient's back and buttocks with baby powder after bathing c) Use a turn sheet lifted by two staff member to move the client in bed | C) Use a turn sheet lifted by two staff member to move the client in the bed |
| While changing a patient's dressing the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wounds drainage: a) Purulent b) Serous | A) Purulent |
| Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patient's Stage III sacrel pressure ulcer: a) Administer the ordered PRN oral opoid 30 min before the dressing change b) Soak the old dressing with sterile saline a few minutes before removing them | A) Administer the ordered PRN oral opiod 30 min before the dressing change |
| The aspect of an older adult's history indicating a risk, for developing hyperatremia is that the client: c) Takes an over the counter antacid d) Has had frequent urinary tract infections | C) Takes an over the counter antacid |
| A client with acute pancreatitus has an abnormally low serum calcium level. During a bath the nurse cleans the client's face with a cloth, and the lips, nose, and side of the face. When documenting this information the nurse would state that the patient's facial twitching indicates the presence of: c) Chrostek's sign d) Bell's palsey | C) Chrostek's Sign |
| The nurse teaching a 32 year old man with renal failure about the path physiologic mechanism of acid-base balance recognize that the instructions have been understood when the client says: a) I lose too much acid through my kidneys b) My breathing increases to correct imbalances | B) My breathing increases to correct imbalances |
| The nurse is caring for an 80 year old female nursing home resident who has been admitted to the hospital with pneumonia and is becoming progressively more confused. Her vital signs are: Temp 101' F, Pulse 112, Resp. 28 and BP 100/70. ABG results include pH 7.50, PaCO@ 25 mmHg, and bicarbonate level 18 mEq/L. The nurse interprets these findings to indicate: a) Respiratory acidosis secondary to hypoexmia b) Respiratory acidosis secondary to anxiety | A) Respiratory acidosis secondary to hypoeximia |
| The edges of a patient's appendectomy incision are approximated, and no drainage is noted. The nurse documents on the client's wound record that the incision appears to be healing by: a) Primary intention b) Secondary intention | A) Primary Intention |
| The nursing action most appropriate for a client who has an infection and develops a fever of 99.8' F is to: a) Continue to monitor the patient's temp b) Administer an antipyretic | A) Continue to monitor the patient's temp |
| In discussing diet modifications the nurse encourages a client with cellulitus and severe inflammation to include: c) Pretzels d) Citrus fruit | D) Citrus Fruit |
| At SAM, a nurse checks the amount of solution left in a potential nutrition infusion bag for an assigned client. It is a 3000 mL bag with 1000 mL remaining. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at: a) Noon b) 2 pm | A) Noon |
| When assessing the patient who has a lower urinary infections (UTI), the nurse will initially ask about: c) Poor urine output d) Pain with urination | D) Pain with urination |
| The patient has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client: c) Encourage the client to use a cathartic laxative on a daily basis d) Place the client on a high fiber diet | D) Place the client on a high fiber diet |
| How should the nurse position a client who is complaining of dyspnea: a) A high fowler's position with two pillows behind the head b) Orthopneic position across the over bed table | B) Orthopneic position across the over bed table |
| The client experienced female circumcision as a puberty ritual while living in Africa as a child. What condition should the nurse monitor the client as an adult: c) Chronic urinary tract infection d) Tendency for postpartum hemorrhage | C) Chronic Urinary Tract Infection |
| A 78 year old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care: c) Insert an indwelling catheter until the symptoms have resolved d) Assist the patient to the bathroom every 2 hours during the day | D) Assist the patient to the bathroom every 2 hours during the day |
| An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease (COPD) to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed: a) Face tent b) Venture Mask | B) Venture Mask |
| The nurse is caring for the patient with clostridum difficile. Which intervention should the nurse implement to prevent nosocomial spread to other clients: a) Wash hands with betadine for 2 min after giving care b) Wear nonsterile gloves when handling GI excretions | B) Wear nonsterile gloves when handling GI excretions |
| A patient with frequent urinary tract infections ask the nurse how she can prevent the reoccurence. The nurse should teach the client to: a) Douche after intercourse b) Void every three hours | B) Void every three hours |
| The nurse is organizing a wellness project to educate teenagers about keeping their bodies healthy. Which information about diet and exercise should be included: a) Diet is the most important predictor of health b) The most important factors for maintaining health are diet and activity | B) The most important factors for maintaining health are diet and activity |
| Which information obtained during the nurse assessment of the patient's nutritional- metabolic pattern may indicate the risk for musculoskeletal problems: c) The patient is 5 ft. 2 inches and weighs 180 lbs. d) The patient prefers whole milk to nonfat milk | C) The patient is 5 ft. 2 inches and weighs 180 lbs. |
| The 45 year old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How does the nurse interpret this assessment data: c) If both partners share the same lack of desire there is often not a problem d) This situation is so unnatural that some dysfunction is present | C) If both partners share the same lack of desire there is often not a problem |
| Two days after surgery for an Ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialists care for the stoma. The nurse identifies a nursing diagnosis of: a) Anxiety related to effects of procedure on lifestyle b) Disturbed body image related to change in body function | B) Disturbed body image related to change in body function |
| When assessing a 64 year old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit 2 years ago. The nurse will plan to teach the patient about: c) Magnetic reasonable imaging (MRI) d) Dual energy x-ray absorption (OEXA) | D) Dual Energy X-ray Absorption (OXEA) |
| A patient who is suspected of experiencing respiratory distress from a left-sided pneumothorax should be positioned: a) On the right side b) In semi-fowler's position | B) In the Semi-Fowler's Position |
| While the nurse is assessing a 62 year old man, the patient says he does not respond to sexual stimulation the way he did when he was younger. The nurse's best response to the patient's comment is: c) Erectile dysfunction is a common problem with older man d) Tell me more about how your sexual response has changed | D) Tell me more about how your sexual response has changed |
| Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD: a) The patient demonstrates the correct way to pursed lip breathe b) The client lists three signs/symptoms to report to the Health Care provider | A) The patient demonstrates the correct way to pursed lip breathe |
| A patient returns to the clinic with recurrent dysuria after being treated with trimethoprium and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take: a) remind the patient about the need to drink 1000 mL of fluids daily b) Obtain a midstream urine specimen for culture and sensitivity testing | B) Obtain a midstream urine specimen for culture and sensitivity testing |
| A patient complains of pain during circumfusion of the shoulder when the nurse moves the arm behind the patient which question should the nurse ask: a) Do you have difficulty in putting on a jacket b) Are you able to feed yourself without difficulty | A) Do you have difficulty in putting on a jacket |
| As a young adult single mother of a second-grade child has to make a decision regarding the teacher for her child will have in third grade and asks the nurse for advice: All other variables being equal which choice is best: a) A woman with 35 year old of teaching experience b) A man who is 40 years old | B) A man who is 40 years old |
| A 72 year old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper tract infection (UTI): c) Foul smelling urine d) Costovertebral tenderness | D) Costovertebral Tenderness |
| When assessing the musculoskeletal system the nurse's initial action will usually be to: b) Have the patient move the extremities against resistance c) Observe the patient's body build and muscle configuration | C) Observe the patient's body build and muscle configuration |
| The nurse anticipates that osteoposis may result from prolonged immobilization because of: a) Lack of weight bearing, which decreases osteoblastic activity b) Decreased dietary calcium intake | A) Lack of weight bearing, which decreases osteoblastic activity |
| A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care: a) Place a bedside commode near the patient's bed b) Demonstrate the use of the Crede maneuver to the patient | A) Place a bedside commode near the patient's bed |
| The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching: a) In the future I will eat a banana every time I take the medication b) I don't have to have a bowel movement every day | B) I don't have to have a bowel movement every day |
| A 52 year old man is scheduled for an annual physical exam. The nurse will plan to teach the patient about: c) Normal decreases in testosterone level d) Annual prostate specific antigen testing (PSA) | D) Annual prostate specific antigen testing (PSA) |
| The daughter of an 80 year old man is aphastoc after suffering a cerebrovascular accident (stroke) express concern that their father is "always" exposing and playing with himself and his catheter. While they are in the room. Upon assessment the nurse finds the patient pulling on and rubbing his penis. What is the nurse's priority action: b) Assess the client's penis for irritations from the catheter c) ASk the client to keep his linens at waist level when he has visions | B) Assess the client's penis for irritations from the catheter |
| Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider: c) Left-sided flank pain d) Temp 100.1" F | C) Left-Sided Flank Pain |
| During a routine physical, an 11 year old tells the nurse that many students in school are "doing it". How should the nurse respond to this statement: a) Tell the client to talk with parents about sexual matters b) ASk what "doing it" means to the client | B) ASk what "doing it" means to the client |
| The patient has been admitted with complaints of shortness of breath for 2 week duration and has received the nursing diagnosis impaired gas exchange. Which admission laboratory result would support the choice of this diagnosis: a) Increased hematocrit b) Decreased BUN | A) Increased Hematocrit |
| The nurse obtains this information when assessing a 74 year old patient in the outpatient clinic. Which finding os of the highest priority when the nurse is planning care for the patient: c) History of recent loss of balance and fall d) Complaint of left hip aching when jogging | C) History of recent loss of balance and fall |
| The nurse is doing bowel and bladder retraining for the client with oaraplegia. Which of the following is NOT a factor for the nurse to consider: c) Fluid intake d) Sexual Function | D) Sexual Function |
| The nurse uses the PLISSIT format in helping client's who have sexual dysfunction. Which action by the nurse best reflects the "P" section of this format: a) ASk the physician for permission to discuss sexual topics with the client c) Acknowledge the clients spoken and unspoken sexual concerns when providing care | C) Acknowledge the clients spoken and unspoken sexual concerns when providing care |
| A nurse in instructing a hospitalized client with a diagnosis of emphysemia about measures that will enhance the effectiveness of breathing during dyspneic periods. Which of the following position will the nurse instruct the client to assume: c) Sitting in a recliner chair d) Sitting on the side of the bed and leaning on an over bed table | D) Sitting on the side of the bed and leaning on an over bed table |
| The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is: a) Risk for deficient fluid volume related to excessive fluid loss from ostomy b) Disturbed body image related to presence of ostomy | A) Risk for Deficient Fluid Volume related to Excessive Fluid loss from Ostomy |
| The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. Which statement made by the client, would indicate that this client needs further instruction: a) I will replace my cotton blankets with polyester ones b) My son will not be able to smoke when I am around | A) I will replace my cotton blankets with polyester ones |
| The client being admitted from the ED is diagnosed with a fecal impaction. Which nursing intervention should be implemented: c) Administer an oil retention enema d) Prepare for an UGI X-ray | C) Administer an oil retention enema |
| The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a retention catheter. Which action requires that the nurse intervene: c) Using an alcohol based hand cleaner before performing catheter care d) Disconnecting the catheter from the drainage tube to obtain a specimen | D) Disconnecting the catheter from the drainage tube to obtain a specimen |
| Which question should the nurse ask when assessing a patient who has a history of benign prostatic hyperplasia (BPH): c) Has there been a decrease in the force of your urinary stream d) Have you been experiencing any difficulty in achieving an erection | C) Has there been a decrease in the force of your urinary stream |
| Which nursing intervention would be the most beneficial in preparing the patient psychologically for ileostomy surgery: a) Include the patient's family in preoperative teaching sessions b) Encourage the patient to express his or her concerns and to ask questions regarding the management of the ileostomy | B) Encourage the patient to express his or her concerns and to ask questions regarding the management of the ileostomy |
| Upon entering the room, the client is found crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following: B) Determining the nurse's needs for assistance c) Supervision delegated care d) Reassuring the client | B) Determining the nurse's needs for assistance |
| How should the nurse use the JCAHO 2006 National Patient Safety Goals to improve communication among caregivers: a) Review a list of look-a-like sound-a-like drugs used in the organization c) Studying a list of abbreviations that are not to be used throughout the organization d) Use the client's room number as an identifier | C) Studying a list of abbreviations that are not to be used throughout the organization |
| The most appropriate manner in which to state an intervention directed towards assisting a client with ambulation is: a) Assist patient with ambulation b) Ambulate with client, using gait belt, two times daily for 15 minutes | B) Ambulate with client, using gait belt, two times daily for 15 minutes |
| The patient's teaching plan includes this goal, "The patient will select 2 gram sodium diet from the hospital menu for the next three days". Which evaluation method will be best for the nurse to use. When determining whether teaching was effective: a) Check the sodium content of the patient's menu choices over the next three days c) Have the patient list favorite foods that are high in sodium and foods that could be substituted for these favorites d) Compare the patient's sodium intake over the next three days with the sodium intake before the teaching was implemented | D) Compare the patient's sodium intake over the next three days with the sodium intake before the teaching was implemented |
| When providing care using evidence-based practice, the nurses uses: a) Clinical judgement based on experience c) Evidence-based guidelines in addition to clinical expertise d) Evaluation of data showing that the patient outcomes are met | D) Evaluation of data showing that the patient outcomes are met |
| A patient with poor circulation to the feet requires teaching about foot care. Which learning goal should the nurse include in the teaching plan? a) The nurse will demonstrate the proper technique for trimming toenails b) The patient will list three ways to protect the feet from injury by discharge d) The patient will understand the rationale for proper foot care after instructions | B) The patient will list three ways to protect the feet from injury by discharge |
| Immediate surgery is planned for a patient with acute abdominal pain. The question used by the nurse that will elicit the most complete information about the patient's coping-stress tolerance pattern is: b) What do you think caused this abdominal pain c) How do you feel about yourself and your hospitalization d) Are there other major problems that are a concern right now | D) Are there other major problems that are a concern right now |
| Outcome statement is: a) Client will ambulate without a walker by 6 weeks b) Client will ambulate freely in house c) Client will not fall | A) Client will ambulate without walker by 6 weeks |
| To assess a patient's readiness to learn before planning, teaching activities, which question should the nurse ask: a) What kind of work and leisure activities do you do b) What information do you think you need right now c) Do you have any religious beliefs that are inconsistent with the treatment | B) What information do you think you need right now |
| A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior- specific conditions: a) Interpersonal influences b) Perceived benefits of action c) Situational influences | B) Perceived benefits of action |
| A nursing student is learning the application of the nursing process to client care. When questioned by the student about the reason for implementing a nursing diagnosis, the nurse's professor responds: "The nursing diagnosis statement: a) Describes client problems that nurses are licensed to treat c) Includes the disease the client has during the treatment of care d) Helps standardize care for all clients | D) Helps standardized care for all clients |
| Which nursing intervention should be applied to a client with a nursing diagnosis of Risk for Skin Integrity impairment related to immobility: a) Encourage client to eat at least 40% of meals b) Restrict fluid intake c) Keep lines dry and wrinkle free | C) Keep linens dry and wrinkle free |
| The nurse has formulated a diagnosis of Activity Intolerance related to Decreased Airway Capacity for chronic asthma. In looking at the client's coping skills, the nurse realizes that the patient has a vast knowledge about the disease and what exacerbates symptoms in particular situations. The nurse will utilize this information because: a) Strengths can be an aid to mobilizing health and the healing process c) It will be easier for the nurse to educate the client about other interventions d) The nurse wont have to spend time going over the pathology of the client's disease | D) The nurse wont have to spend time going over the pathology of the client's disease |
| The nurse assess a surgical patient in the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate: a) Obtain wound cultures b) document the assessment d) Assess the wound every 2 hours | D) Assess the wound every 2 hours |
| A 76 year old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep granulation tissue. The nurse documents the wound as a: a) Red wound b) Yellow wound c) Full thickness wound | C) Full thickness wound |
| The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern: a) The BP is 90/40 mm/Hg c) Oral fluid intake is 100 mL for the last 8 hours d) There is prolonged skin tenting over the sternum | A) The BP is 90/40 mm/Hg |
| When the nurse is evaluating the fluid balance for a patient admitted for hypervolemia associated with multiple draining wounds, the most accurate assessment to include is: a) Skin turgor b) Daily weight c) Presence of edema | B) Daily Weight |
| A patient is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care: a) Keep the patient positioned on the left side b) Obtain a daily x-ray to verify tube placement c) Check the gastric residual volume every 4 to 6 hours | C) Check the gastric residual volume every 4 to 6 hours |
| A patient with protein calorie malnutrition who has had abdominal surgery is receiving potential nutrition (PN). Which assessment information obtained by the nurse is the best indicator that the patient is receiving adequate nutrition: a) Blood glucose is 110 m/dL b) Serum albumin level is 3.5 mg/dL d) Surgical incision is healing normally | D) Surgical incision is healing normally |
| The nurse receives change-of-shift report about the following four patients. Which patient will the nurse assess first: a) A patient who has malnutrition associated with 4+generalized pitting edema b) A patient whose potential nutrition has 10 mL of solution left in the infusion bag d) A patient who is receiving continuous internal feedings and has new onset crackles throughout the lungs | d) A patient who is receiving continuous internal feedings and has new onset crackles throughout the lungs |
| A patient returns to the surgical nursing unit following a vertical banded gastroplasty with a nasogastric tube to low, intermittent suction and a patient controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care: b) Offer sips of sweetened liquids at frequent intervals c) remind the patient that PCA use may slow the return of bowel functions d) Support the surgical incision during patient coughing and turning in bed | D) Suport the surgical incision during patient coughing and turning in bed |
| Which of these patients in the clinic will the nurse plan to teach about risks associated with obesity: a) Patient who has a BMI of 18 kg/m2 b) Patient with a waist circumference 34 inches (86 cm) d) patient whose waist measures 30 in. (75 cm) and hips measure 34 in. *85 cm) | A) Patient who has a BMI of 18 kg/m2 |
| A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results would the nurse expect to find in this patient: a) pH 7.30, PaCO2 50, HCO3 27 b) pH 7.47, PaCO2 43, HCO3 28 c) pH 7.43, PaCO2 50, HCO3 28 | B) pH 7.47, PaCO2 43, HCO3 28 |
| Which potential potassium order is safe for the nurse to implement: a) Add 20 mEq of KCL to 1,000 mL of IV fluid b) 10 mEq KCL IV over 1-2 min d) 10 mEq KCL SQ | ... |
| The nurse notes that the tube fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What is the nurses priority action: a) Place the client in high fowler's position b) Turn off tube feeding d) Assess the patient's bowel sounds | B) Turn off the tube feeding |
| The nurse is reviewing laboratory data for a patient who is receiving total parental nutrition. Which lab value should be immediately brought to the physicians attention: a) BUN of 60 c) Serum glucose 328 d) Potassium of 3.5 | A) BUN of 60 |
| After completing a scheduled every 2-hour turn by turning the patient to the left side, the nurse notices a reddened are over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area: a) Reactive hyperemia c) Stage II pressure ulcer d) Stage III pressure ulcer | A) Reactive Hyperemia |
| A patient substained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear and edematous. The nurse identifies the stage of healing of these wounds as long: a) Inflammatory b) Proliferate d) Remodeling | ... |
| The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take: a) Notify the patient's health care provider b) Give the prescribed PRN lorazepam (ativan) c) Start the prescribed PRN oxygen at 2 to 4 L/min | ... |
| A patient is receiving 3% NaCl solution for correction of hypoatremia. During administration of the solution, the most important assessment for the nurse is to monitor is: a) Lung sounds c) Peripheral pulses d) Peripheral edema | ... |
| When the nurse assesses dyspnea in a client with congestive heart failure, she assesses for other manifestations of fluid volume excess including: b) Peripheral Edema c) Increased hematocrit level d) decreased urine output | ... |
| A client has a serum sodium concentration of 160 mEq/L and exhibits generalized weakness and confusion. The nurse should plan to initiate: a) Fluid restrictions c) Monitoring of urine specific gravity d) Seizure precautions | A) fluid restrictions |
| When the body is subjected to invasion or trauma, the role of Europhiles is to: b) Release histamine into the circulation c) Produce specific antigens d) Phagocytize injurious agents | ... |
| A patient complains of not having had a bowel movement since being admitted 2 days ago for multiple fractures of both lower legs. The patient is on bedrest and has skeletal traction. Which intervention would be the most appropriate nursing action: a) Administer an enema c) Ensure maximum fluid intake (3000 mL/day) d) Perform range of motion exercises to all extremeties | ... |
| The nurse is caring for a patient diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first: a) Take the client's vital signs b) Check the client's pulse oximetry c) Administer oxygen via nasal cannula | C) Administer oxygen via nasal cannula |
| While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm: b) Move the wash basin farther toward the foot of the bed so the client must reach c) Have the client brush their hair and teeth d) Move each of the patient's hand and arm joints through passive range of motion | C) Have the client brush their hair and teeth |
| The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in the client's plan of care: a) Weight-bearing activities to stimulate joint relaxation b) Range of motion exercises to prevent worsening of contractures c) Exercises to strengthen flexor muscles | B) Range of motion exercises to prevent worsening of contractures |
| The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client: a) Institute an exercise plan that includes weight-bearing activities b) Protect the client's bones with strict bed rest d) Provide the client with assisted range of motion exercising twice daily | D) Provide the client with assisted range of motion exercising twice daily |
| Which statement made by a post menopausal client, would the nurse evaluate as indicating the need for further assessment: a) For some reason, I have more sexual desire than ever c) I am so glad that I don't need to worry about sex anymore d) Sex certainly takes longer that it used to, but im getting used to that | C) I am so glad that I don't need to worry about sex anymore |
| Which problem is most appropriate for the nurse to identify for the client with diarrhea: a) Alteration in skin integrity b) Chronic pain perception d) INeffective coping | ... |
| Upon assessment the nurse notes that the client is dyspneic; has bibasilar crackles, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details: b) Anxiety c) Ineffective airway clearance d) Impaired gas exchange | C) Ineffective Airway Clearance |
| The RN should incorporate which instructions into the teaching plan for a client with a urinary diversion: b) Notify the physician if the stoma is deep pink and shiny c) Strands of blood appear in the urine d) Increase fluid intake | ... |
| The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse: b) Palpate for bladder fullness c) Inspect the sacrel area for edema d) Use the PRN order to medicate the client with an antacid | C) Inspect the sacrel area for edema |
| Role Ambiguity: Don't know if I'm ready to be a mom: | Negative self-esteem |
| Mild anxiety: | Perception and learning is enhanced |
| Series of "small successes is positive way to help clients True or False | True |
| Healing Touch: | Realign energy flow |
| Can you use essential oils for Asthma: True or False | True |
| People in crisis - can they work through crisis if someone works with them | Yes |
| A home health nurse is working with a patient who quit his job after injury- life has no meaning and lonely- everyone has left him- what is this a sign of: | Spiritual Distress |
| Normal Range for pH: | 7.35- 7.45 |
| Normal Range for: PaCO2 | 35-45 mm Hg |
| Normal Range for HCO3: | 21-28 mEq/L |
| The nursing process is a dynamic process. This means that it: a) Is ever changing to the client's needs b) Conveys the force or power of the health team | A) Is ever changing in response to the client's needs |
| During the assessing component of the nursing process, the primary reason for interviewing the client is to: c) Provide emotional therapy d) Collect data | D) Collect Data |
| Formulating nursing diagnoses and client strengths is a joint function of: c) Nurse and client d) Physician and client | C) Nurse and client |
| What is wrong with the following outcome? Client will be able to climb one flight of stairs without shortness of breath: a) Nothing is wrong b) No target time is given | B) No target time is given |
| A client with diabetes who needs to learn to inject his own insulin states, "Ive had a good night's sleep, so let's tackle that syringe." The client if showing: a) Feedback c) Readiness | c) Readiness |
| Which of the following nursing diagnosis pertains to a client's learning needs: b) Altered health maintenance related to knowledge deficit: catheter care d) Anxiety related to wife's illness | B) Altered health maintenance related to knowledge deficit: catheter care |
| Which factor reduces the risk of electrical hazards: a) two-pronged electrical plugs b) Three-prolonged electrical plugs | B) Three-prolonged electrical plugs |
| A client has just returned to his room after undergoing exploratory abdominal surgery. The nurse notes watery red drainage on his dressing. The nurse will describe the drainage as: | Sanguineous |
| Purulent: | Pus |
| Serous: | Clear |
| Sanguineous: | Red |
| Serous Sanguineous: | Clear and blood tinged |
| A client has an open wound that is yellow and black. Using the RYB color code, which nursing intervention needs to occur first? a) Debride the area with wet-to-dry dressing b) Apply topical antibiotic ointment | A) Debride the area with wet-to-dry dressing |
| Red: | Cover |
| Yellow: | Clean |
| Black: | Debride |
| To reduce shearing force for a bedridden client. It is most important for the nurse to: A) Put bed in high Fowler's position b) Pull the client up in at least once an hour | a) Put bed in high Fowler's position |
| To help alleviate spiritual distress effectively, the nurse must: b) offer to pray with the client d) find out what the client perceives his/her spiritual needs to be | d) find out what the client perceives his/her spiritual needs to be |
| Coping with stress differs from adaption to stress in that: a) coping is a more immediate, short term response to stress b) Coping is a later response to stress | a) Coping is a more immediate, short term response to stress |
| Which of the following are considered defense mechanisms: b) denial c) Sublimation | d) denial |
| Which behavior is characteristic of someone who is coping well with stress: c) Sets aside 30 min a day to exercise d) has no hobbies | C) Sets aside 30 min a day to exercise |
| Which are the following are normal physiological changes that occur during non- REM sleep: b) Decrease in pulse d) drop in basal metabolic rate | B) Decrease in pulse |
| During which stage of NREM sleep would you expect a client to be most difficult to arouse: c) Stage III d) Stage IV | d) Stage IV |
| A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? c) Have you had chest pain with or without activity d) Do you have difficulty with daytime sleepiness | D) Do you have difficulty with daytime sleeping |
| Because of significant concerns about financial problems a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? By day 5, the client will: b) Report falling asleep within 20 to 30 minutes c) Have a plan to pay all bills | B) Report falling asleep within 20 to 30 minutes |
| A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? c) Discontinue taking the pills d) Continue taking pills and discuss tapering the dose with the primary care provider | D) Continue taking the pills and discuss tapering the dose with the primary care provider |
| During a well-child visit, a mother tells the nurse that her 4- year old daughter typically goes to bed at 10:30 pm and awakens each morning at 7 am. She does not take a napin the afternoon. Which is the best response by the nurse: a) encourage the mother to consider putting her daughter to bed between 8 and 9 pm d) Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap | A) Encourage the mother to consider putting her daughter to bed between 8 and 9 pm |
| A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurse's assessment? Select all that apply: a) Amount of sleep he usually obtains during the week and on weekends b) How much alcohol he usually consumes c) Onset and duration of symptoms d) Whether or not his classes are boring e) What medications including herbal remedies, he is taking | a) Amount of sleep he usually obtains during the week and on weekends c) Onset and duration of symptoms e) What medications, including herbal remedies, he is taking |
| Prior to finalizing a family orientated nursing care plan and implementing interventions, it is essential for the nurse to perform which of the following: a) Meet with all family members simultaneously c) establish a trusting relationship with the family as a group | C) establish a trusting relationship with the family as a group |
| Nurses often utilize systems theory to assess family units. Which example illustrates a family unit that does NOT meet the criteria of a well-functioning system? c) Each member's personal boundaries are well defined d) The primary activities of each member focus on personal purposes | D) The primary activities of each member focus pn personal purposes |
| What is primary function of a family? a) Provide everything each member wants b) Provide an environment that supports growth of individuals | B) Provide an environment that supports growth of individuals |
| The shift change while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following initial greetings is most appropriate: a) I'm very sorry for your loss b) I'll take you in to view the body | A) I'm very sorry for your loss |
| At which age does a child begin to accept that he or she will someday die: c) 9-12 years old d) 12-18 years old | c) 9-12 years old |
| When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response: a) Tell me what it means to you to have surgery b) you must be very glad to be having this lesion removed | A) Tell me what it means to you to have surgery |
| The client has been close to death for some time and the family asks how the nurse will know when the client has actually died,. Which of the following would be the most accurate response from the nurse: c) When there is no apical pulse d) When the extremities are cool and dark in color | C) When there is no apical pulse |
| Which client is at greatest risk for experiencing sensory overload: c) A 16 year old listening to loud music d) An 80 year old client admitted for emergency surgery | D) An 80 year old client admitted for emergency surgery |
| An 80 year old client is transferred to a long term care facility. On the second night, he becomes confused and agitated. What is the most appropriate nursing diagnosis? c) Disturbed Sensory Perception d) Disturbed Thought Process | C) Disturbed Sensory Perception |
| The nursing diagnosis Risk for Impaired Skin Integrity related to sensory-perception disturbance would best fit a client who: a) Cut a foot by stepping on broken glass b) Uses a wheelchair due to paraplegia | B) Uses a wheelchair due to paraplegia |
| Which statement indicates the client needs a sensory aid in the home: a) I tripped over that throw rug again b) I can't hear the doorbell | B) I can't hear the doorbell |
| A client is exhibiting signs and symptoms of acute confusion/delirium. Which strategy should the nurse implement to promote a therapeutic environment: c) keep the room organized and clean d) Use restraints for client safety | C) Keep the room organized and clean |
| An 85 year old client has impaired hearing. When creating the care plan which intervention should have the highest priority: a) Obtaining an amplified telephone b) Teaching the importance of changing his position | A) Obtaining an amplified telephone |
| When the client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments? a) pain tolerance b) Pain intensity | B) Pain Intensity |
| A client who describes his pain as 6 on a scale of 1 to 10 is classified as having which of the following: c) Moderate to severe pain d) Very severe pain | C) Moderate to severe pain |
| During an admission nursing assessment, a client with diabetes describes his leg pain as a "dull, burning sensation." The nurse recognizes this description to be characteristic of which type of pain: c) Visceral d) Neuropathic | D) Neuropathic |
| Which statement best reflects the nurse's assessment of the fifth vital sign: a) Do you have any complaints b) Are you experiencing any discomfort right now | B) Are you experiencing any discomfort right now |
| A client recovering from abdominal surgery refuses analgesia, saying that he is "fine, as long as he dosen't move." Which nursing diagnosis should be a priority: A) Deficient Knowledge (pain control measures) b) Ineffective Health Maintenance | A) Deficient Knowledge (pain control measures) |
| Characteristic normal urine: | Transparent |
| Scan amount of urine 100-500 mL a day: | Oliguria > 500 mL, low urine output |
| Advantage of Ileal conduit: | > chance of ascending kidney infection |
| Purpose of a urinary catheter: | Amount of residual urine |
| Urine output: | Alert physician if below 30 mL/hr |
| Promotes normal defecation: | Privacy |
| Colostomy stoma, dark blue in color: | Call physician |
| Contributes to constipation: | Prolonged use of laxatives |
| Incontinence, assess in client: | laughing leakage |
| 1st BM since surgery, hard/dry formed stool: | Constipation |
| At risk for difficulty urination elimination: | 80 year old male, frequent urination at night |
| Nuring Diagnosis appropriate for client with indwelling catheter, bag is on the floor: | Risk for Infection |
| Outcome/ Goal, urinary pattern alteration related to enlarged prostate: | Avoid Bladder Distension |
| Nursing intervention, preventing UTI: | Empty Bladder Completely |
| Indwelling catheter securing: | Preventing trauma from external structures |
| Bactrum BID, E.Coli, UTI: | Take antibiotic for full amount time, finish them all |
| Most important for nurse, on sexual problems: | Know how you feel first |
| 5 year old son playing naked with another boy: | Get boys interested in another activity |
| 80 year old worried no BM every day, nurse should say: | It's normal to go 2x a week |
| Prevention of UTI when patient states: | Empty bladder every 3/4 hrs. throughout day |
| Pyridium: | Urine will turn florescent orange |
| 87 year old dehydration, incontinent urine, nursing action best for care: | Assist patient to restroom every 2 hours |
| Home health nurse teacher patient about straight catheter, effective statement by patient: | Clean catheter before and after each use |
| Two days after surgery, patient wont participate with care and will only let ostomy nurse provide care: | Disturbed Body Image |
| 88 year old, distended bladder, hyperplasia, agitated, confusion, intervention used 1st: | Put in catheter |
| Low-residue diet to prevent constipation instruct client to: | Increase fluid intake |
| Bedpan verses on toilet: | Sitting position increase pressure in abdomen |
| Why her husband has condom catheter verses catheter inside: | Prevents Infection |
| usually uses fleet enema, response by nurse: | Are you taking any Vitamin supplements |
| Actions by client effective in teaching: | Clients walks alot |
| 38 year old female, boyfriend wants to have sex after smoking marijuana, nurse says: | Marijuana enhances sexual functioning |
| Diagnosis of diarrhea, day of admission, diet to be ordered: | Clear liquids with Gatorade |
| Bladder Infection, most important to report to Dr: | Flank pain |
| 62 year old man, dosen't respond to sexual stimulation, nurse response: | Tell me more |
| 52 year old man for physical exam, teach patient about: | Practice/Prostate exams |
| Stress incontinence, nutrition therapy, need more teaching: | Limit total intake of fluids |
| Homosexual, worried about him, nurse should consider the factor of saying: | What constitutes, varies among religion |
| 45 year old had no interest in sex, not in 16 years, nurse interprets: | Both parents share lack of desire there is no problem |
| Stop intercourse before orgasm to not get pregnant; | Conceiving isn't related to orgasm |
| Adult masturbating, nurse should: | Excuse me and leave the room |
| Sexual history on admission: | Sexual history varies on case by case basis |
| Clinic with recurrent dysuria, and taking Bactrum, nurse should: | Get culture |
| 62 year old female- laugh/cough/ leakage of urine, intervention of care plan: | Teach Kegal Exercises |
| Rectal surgery, aptient urinates 50 mL of urine, every 30-60 kin, nurse should: | Perform a bladder scan |
| Nursing action most helpful decreasing risk of hospital acquired infections, in urinary tract: | Avoid unnecessary catheters |
| Plan of care, chronic constipation, which foods nurse should emphasize: | Greens |
| NAP taking action to get urinary specimen, action requires nurse intervene: | Disconnecting catheter drainage tube |
| Client statements indicates Pyridium is effective: | Less bladder pain/burning |
| client at greater risk for bladder infection: | Female not taking estrogen therapy- females at greater risk |
| Post menopausal, infection, why is this happening now, nurse says: | Estrogen levels, more susceptible |
| Nurse ask when history of BPH: | Decrease in force of urinary stream |
| Colonoscopy, nurse action: | Have them sign informed consent |
| Assessing UTI labs, finding immediate intervention: | Left shift of WBCs |
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