Fundamentals of Nursing Midterm

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply)

a. A client who has terminal cancer requests hospice care in the home.
b. A client asks about community resources available for older adults.
c. A client states, "I would like to have my child baptized before surgery."
d. A client requests an electric wheelchair for use after discharge.
e. A client states, "I do not understand how to use a nebulizer."
Click the card to flip 👆
1 / 357
Terms in this set (357)
A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply)

a. A client who has terminal cancer requests hospice care in the home.
b. A client asks about community resources available for older adults.
c. A client states, "I would like to have my child baptized before surgery."
d. A client requests an electric wheelchair for use after discharge.
e. A client states, "I do not understand how to use a nebulizer."
a. A client who has terminal cancer requests hospice care in the home.
b. A client asks about community resources available for older adults.
d. A client requests an electric wheelchair for use after discharge.
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team?

A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist
D. Occupational therapist
A client who is postoperative following knee arthroplasty is concerns about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply)

A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist
A. Provider
C. Pharmacist
D. Registered nurse
A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team?

A. Social worker
B. Certified nursing assistant
C. Occupational therapist
D. Speech-language pathologist
D. Speech-language pathologist
A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following activities should she include? (Select all that apply)

A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level
E. Measuring vital signs
A. Bathing
B. Ambulating
C. Toileting
E. Measuring vital signs
A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which if the following ethical principals?

A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
B. Autonomy
A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following principals?

A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
D. Nonmaleficence
A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principals?

A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
C. Justice
A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principals?

A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
D. Nonmaleficence
A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma?

A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment
B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints
C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill
D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form
C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill
A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assault B. Battery C. False Imprisonment D. Invasion of privacyA. AssaultA nurse is caring for a competent adult client who tells the nurse, " I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False Imprisonment C. Negligence D. Breach of confidentialityB. False ImprisonmentA nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."C. "I plan to write that I don't want them to keep me on a breathing machine."A nurse is caring for a client who is about to undergo elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) A. Make sure the surgeon obtained consent. B. Witness the client's signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgeryA. Make sure the surgeon obtained consent. B. Witness the client's signature on the consent formA nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room during a break time. Which of the following actions should the nurse take? A. Alert the American Nurses Association B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleepC. Report the observations to the nurse manager on the unitBy the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain.A. Reassess the client to determine the reasons for inadequate pain relief.A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. EvaluationA. AssessmentA charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply) A. Respiratory rate is 22/min with even unlabored respirations B. The client's partner states "He said he hurts after 10 min of walking C. Pain rating is 3 on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The assistive personnel report the client walked with a limpA. Respiratory rate is 22/min with even unlabored respirations D. Skin is pink, warm, and dry E. The assistive personnel report the client walked with a limpA charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting an NG tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning client every 2hr to reduce pressure ulcer riskC. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning client every 2hr to reduce pressure ulcer riskA nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning steps of the nursing process? A. I will determine the most important client problems that we should address B. I will review past medical history on the client's record to get more information C. I will go carry out the new prescriptions from the provider D. I will ask the client if the nausea has resolvedA. I will determine the most important client problems that we should addressA nurse is caring for a client who is 24hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurses report and prescribes a full liquid clear diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. IntegrityA. BasicA nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription or a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk-taking D. CreativityB. ResponsibilityA newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply) A. Find a mentor B. Use a journal to write about the outcomes of clinical judgements C. Review articles about EBP D. Limit consultations with other professionals involved in a client's care E. Make quick decisions when unsure about a client's needsA. Find a mentor B. Use a journal to write about the outcomes of clinical judgements C. Review articles about EBPA nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to father info about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication info? A. Knowledge B. Experience C. Intuition D. CompetenceA. KnowledgeA nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. DisciplineD. DisciplineA nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. RestatingB. ReflectingWhich of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply) A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Sit facing the clientA. Use an open posture C. Establish and maintain eye contact E. Sit facing the clientA nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply) A. "You will do great! You just have to get used to it." B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally distributed between the nurse's and client's desires B. Encourage the client to communicate their thoughts and feelings C. Give the nurse-client communication no time limits D. Allow communication to occur spontaneously throughout the nurse-client relationshipB. Encourage the client to communicate their thoughts and feelingsA nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication. which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed postureB. Sit at eye level with the childA nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with client and family members? (Select all that apply) A. Talk to the interpreter about the family while the family is in the room. B. Determine client understanding several times during the conversation. C. Look at the interpreter when asking the family for questions. D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk.B. Determine client understanding several times during the conversation. D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk.A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. Members of the same religion share similar feelings about their religion. B. A shared religious background generates a mutual regard for one another. C. The same religious beliefs can influence individuals differently. D. The nurse and client should discuss the differences and commonalities in their beliefs.C. The same religious beliefs can influence individuals differently.A nurse enter the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. Contact the hospital's spiritual services. B. Ask what is making the client cry. C. Ensure no visitors or staff enter the room for a short period of time. D. Turn on the television for a distraction.C. Ensure no visitors or staff enter the room for a short period of time.A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. "I will make sure the menu includes kosher options." B. "I will ask the client if they want to schedule some times to pray during the day." C. "I will avoid discussing care when the client's family is around." D. "I will make sure daily communion is available for this client."B. "I will ask the client if they want to schedule some times to pray during the day."A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. "I believe in this case you should really make an exception and accept the blood transfusion." B. "I know your family would approve of your decision to have a blood transfusion." C. "Why does your religion mandate that you cannot receive any blood transfusions?" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."The client has a 6 inch laceration on his right forearm. The arm develops an infection. Which of the following is a sing of an acute inflammatory process? a. A blanching of the skin b. A decrease in temperature at the site c. A decrease in the number of white blood cells d. A release of histamine that adds to the pain responsed. A release of histamine that adds to the pain responseA female client has been undergoing diagnostic testing since admission to the medical unit in the hospital. The results of blood testing are sent back to the unit. Upon reviewing the results, the nurse will report which of the following findings to the physician, which is abnormal? a. Erythrocyte sedimentation rate (ESR) 35mm/hr b. White blood cell (WBC) count 8000/mm3 c. Neutrophils 65% d. Iron 75g/100mLa. Erythrocyte sedimentation rate (ESR) 35mm/hrThe nurse is observing the new staff member work with the client. Of the following activities, which one has the greatest possibility of contributing to a nosocomial infection and requires correction? a. Washing hands before applying dressing b. Taping a plastic bag to the bed rail for tissue disposal c. Placing a Foley catheter bag on the bed when transferring a client d. Using alcohol to cleanse the sink before starting and intravenous linec. Placing a Foley catheter bag on the bed when transferring a clientDroplet precautions will be instituted for the client admitted to the infectious disease unit with: a. Streptococcal pharyngitis b. Herpes simplex c. Pertussis d. Measlesa. Streptococcal pharyngitisIn a small rural hospital they work with a wide variety of clients. Of this afternoon clients admitted, the nurse acknowledges the client with the highest susceptibility to infection is the individual with: a. Burns b. Diabetes c. Pulmonary emphysema d. Peripheral vascular diseasea. BurnsA nurse must display understanding of the mental implications of a client on isolation precautions when planning care to control the risk of: a. Denial b. Aggression c. Regression d. Isolationd. IsolationSurgical aseptic techniques are employed by a nurse when: a. Inserting an intravenous catheter b. Placing soiled linen in a moisture-resistant bag c. Disposing of syringes in puncture-proof containers d. Washing hands before changing a dressinga. Inserting an intravenous catheterA nurse is changing the dressing and accidentally drops the packing onto the clients abdomen. The client has a large, deep abdominal incision that is packed with sterile half-inch packing and covered with a dry 4x4 gauze. The nurse should: a. Add alcohol to the packaging and insert it into the incision b. Throw the packaging away, and prepare a new one c. Picking up the packaging with sterile forceps, and gently place it into the incision d. Rinse the packaging with sterile water, and put the packaging into the incision with sterile glovesb. Throw the packaging away, and prepare a new oneA client has a viral infection. Which of the following is typical of the illness stage of the course of her infection? a. There are no longer any acute symptoms b. An oral temperature reveals a febrile state c. The client was first exposed to the infection 2 days ago but has no symptoms d. The client feels sick but is able to continue her normal activitiesb. An oral temperature reveals a febrile stateThe nurse recognizes that special care must be taken in the handling of which of the following to prevent the transmission of hepatitis A? a. Blood b. Feces c. Saliva d. Vaginal secretionsb. FecesThe parent of a preschool child asks the nurse how chickenpox (varicella zoster) is transmitted. The nurse identifies that the virus is: a. Carried by a vector organism b. Carried through the air in droplets after sneezing or coughing c. Transmitted through person-to-person contact d. Acquired through contact with contaminated objectsb. Carried through the air in droplets after sneezing or coughingWhile working with clients in the postoperative period, the nurse is very alert to the results of laboratory tests. Which one of the following results is indicative of an infectious process? a. Iron 80g/100mL b. Neutrophils 65% c. White blood cells (WBC) 18,000/mm3 d. Erythrocyte sedimentation rate (ESR) 15mm/hrc. White blood cells (WBC) 18,000/mm3Which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a client? a. Covering the mouth and nose when sneezing b. Wearing disposable gloves c. Isolating client articles d. Changing soiled dressingsd. Changing soiled dressingsIn preventing and controlling the transmission of infections, the single most important technique is: a. Hand hygiene b. The use of disposable gloves c. The use of isolation precautions d. Sterilization of equipmenta. Hand hygieneA client with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this client to the unit will require the implementation by the staff of: a. Airborne precautions b. Droplet precautions c. Contact precautions d. Reverse isolationa. Airborne precautionsThe nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? a. Clean forceps may be used to move items on the sterile field b. Sterile fields may be prepared well in advance of the procedures c. The first small amount of sterile solution should be poured and discarded d. Wrapped sterile packages should be opened starting with the flap closest to the nursec. The first small amount of sterile solution should be poured and discardedOlder adult clients may react differently to infectious processes and a nurse suspects that her older adult client may be experiencing hypostatic pneumonia. The nurse must be alert to atypical signs and symptoms, such as: a. Hypotension b. Confusion c. Erythema d. Chillsb. ConfusionWhat is the correct order for a nursing assistant for putting on the protective equipment when caring for a client in isolation? a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves b. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves c. Wash her hands, put on the gown, apply the mask and eyewear, and then apply the gloves d. Put on the gown, apply the mask and eyewear, wash her hands, and then apply glovesa. Wash her hands, apply the mask and eyewear, put on the gown, and then apply glovesA client has requires a mid-abdominal surgical incision which necessitates a sterile dressing. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: a. Put sterile gloves on before opening sterile packages b. Discard packages that may have been in contact with the area below waist level c. Place the cap of the sterile solution well within the sterile field d. Place sterile items on the very edge of the sterile drapeb. Discard packages that may have been in contact with the area below waist levelThe nurse is preparing to assist with a sterile procedure in the surgical suite. An appropriate technique that the nurse includes in the surgical scrub is to: a. Keep the hands below the elbows throughout the scrub b. Use the brush on the palms and dorsal surfaces of the hands c. Maintain the scrub for at least 2 to 5 minutes d. wash well around all jewelryc. Maintain the scrub for at least 2 to 5 minutesAn appropriate isolation procedure for the nurse to implement when working with a client who is found to have methicillin-resistant Staphylococcus aureus (MRSA) is to: a. Leave all linen in the client room b. Place the specimen containers in plastic bags for transport c. Wipe the stethoscope off before removing it form the room d. Remove the mask and goggles first when leaving the clients roomb. Place the specimen containers in plastic bags for transportA client is found to have a bacterial infection of Escherichia coli. The nurse, recognizing the effects of this bacterium, anticipates that the client will demonstrate: a. Diarrhea b. Coughing c. Cold sores around the mouth d. Discharge from the eyesa. DiarrheaWhich of the following clients is at greatest risk for acquiring an infection? a. A 56-year-old with a urinary catheter 2 days after prostatectomy b. A 27-year-old diagnosed with human immunodeficiency virus (HIV) c. A 43-year-old who is 3 days post appendectomy and is currently afebrile d. A 16-year-old with a compound fractured femur as a result of a bike accidentd. A 16-year-old with a compound fractured femur as a result of a bike accidentA nurse is caring for a client who has colonized methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements reflects the best understanding of the clients condition? a. This client has the bacteria present but it hasn't become infected. b. This makes the clients MRSA very infectious and so a danger to others. c. Just be sure to follow standard precautions and there wont be a problem. d. The client needs to be watched closely for a conversion to active MRSA.a. This client has the bacteria present but it hasn't become infected.The greatest drawback to the routine use of antibacterial hand soaps and gels is that they: a. Are expensive b. Irritate the skin c. Kill resident flora d. Encourage resistant bacteriab. Irritate the skinThe nurse knows that Staphylococcus aureus found normally on the skin of a client who has had surgery poses a particular risk for that client developing: a. A cold sore b. Gastroenteritis c. A wound infection d. A urinary tract infectionc. A wound infectionWhat is the most appropriate answer to the clients question, Whats the difference between antibacterial and antimicrobial hand soaps? a. There is no real difference; use the less expensive. b. Antibacterial soaps are more effective at preventing infections. c. Antimicrobial soap is better since it wont kill the good bacteria on the skin. d. Any soap will do; its the technique for proper hand washing that is the key.c. Antimicrobial soap is better since it wont kill the good bacteria on the skin.A presurgical client asks the nurse why it seems so easy to get an infection in the wound after surgery. The nurses most appropriate response to this question is: a. The contaminated dressing acts as a breeding ground for microorganisms that then infect the wound. b. The body's immune system is weakened by the surgery and cant fight off the infection as effectively. c. While infections occur, there are many very effective antibiotics available to help minimize the risk of that happening. d. The surgical wound provides the microorganisms on the surrounding skin a path to enter deep into the body's tissues.d. The surgical wound provides the microorganisms on the surrounding skin a path to enter deep into the body's tissues.The nurse obtains a new, dry nebulizer when preparing to give an elderly asthmatic client a nebulizer treatment because the risk of infection is increased because: a. The clients age increases the risk factor for potential infection b. The clients immune system is compromised as a result of asthma c. There is a potential presence of Pseudomonas organisms in the reservoir d. There is a chance for microorganisms to enter the body via the respiratory systemc. There is a potential presence of Pseudomonas organisms in the reservoirA client is told that he is a carrier of the hepatitis B virus. When asked to explain this situation in more detail, the nurses best response is: a. You need to be careful not to pass the virus to other people. b. You aren't sick, but you do have the virus within your body. c. Be tested often so as to monitor whether the virus becomes active. d. While you show no signs of the illness, you can pass the virus to others.d. While you show no signs of the illness, you can pass the virus to others.The nurse can best minimize the risk for infection when initiating an intravenous site by: a. Proper vein site selection b. Effective topical skin preparation c. Appropriate site dressing d. Gloving for the procedureb. Effective topical skin preparationA client enters a neighborhood walk-in clinic reporting the symptoms of a head cold. When the health care provider does not prescribe an antibiotic, the client asks the nurse to explain why not. The nurses most appropriate response is: a. Antibiotics aren't usually necessary for colds, and they are really very expensive if you don't have insurance. b. You know what they say; a cold will go away with medication in 2 weeks; without medication in 14 days. c. Your health care provider believes in treating the symptoms since there are so many different strains of the common cold. d. Common colds don't usually require an antibiotic, and taking one results in making it harder to treat infections when they do occur.d. Common colds don't usually require an antibiotic, and taking one results in making it harder to treat infections when they do occur.The nurse is caring for a postoperative client with a localized sinus infection. The most appropriate means by which the nurse can minimize the risk of this client developing a systemic infection is to: a. Adhere strictly to standard precaution techniques b. Dispense prescribed anti-infective medication as ordered c. Monitor the client regularly for exacerbation of the sinus infection d. Review lab work daily to determine the presence of increased white cell counta. Adhere strictly to standard precaution techniquesThe nurse and a client are discussing the clients tendency to develop numerous colds during the winter months. The clients health history reveals that he is a 1 pack a day smoker. Which of the following nursing statements is most appropriate regarding the possible relationship between the clients cigarette smoking and the frequency of winter colds? a. Smoking decreases your body's immune system, and so you cant fight off the colds as effectively. b. If you stopped smoking you would have fewer colds and just generally feel better all year around. c. The nicotine in the cigarettes has an effect on your blood vessels, decreasing the circulation of antibodies that would attack the cold viruses. d. Smoking damages the little hairs in your nose and airways so they cant trap the airborne cold viruses and keep them from entering your body.d. Smoking damages the little hairs in your nose and airways so they cant trap the airborne cold viruses and keep them from entering your body.Which of the following clients is at greatest risk for acquiring a health care associated (nosocomial) infection? a. A 32-year-old hospitalized for 2 days for migraine headaches b. A client with type 1 diabetes who has been experiencing hypoglycemia c. A trauma victim taken directly from the ED to surgery and then to the post-surgical unit d. A pregnant 24-year-old diagnosed with both sinusitis and otitis media and prescribed an oral antibioticc. A trauma victim taken directly from the ED to surgery and then to the post-surgical unitA client is admitted for treatment of various poorly healing, infected leg ulcers. The nurse recognizes that the clients nutritional history is of primary importance since: a. Nutrition is vital to the clients overall health status b. The clients food intake will likely be decreased as a result of the illness c. Wound healing and infection prevention are negatively impacted by poor nutrition d. The clients habits regarding food intake are directly related to this hospitalizationc. Wound healing and infection prevention are negatively impacted by poor nutritionA client admitted for an abdominal hysterectomy reports that she has been under a lot of stress since the death of her mother and wonders how that will affect her surgery and recovery. Which of the following nursing statements reflects the most therapeutic response to the clients question? a. Being under stress isn't going to help your recovery; you need to relax and focus on yourself and getting well. b. Your mothers death must be very stressful for you but she would want you to concentrate on getting healthy. c. Stress does have a negative effect on the body's ability to heal; is there anything I can do to help you minimize the stress you feel? d. Your health care provider can prescribe you some medication to help you cope with the stress; would you like me to mention it?c. Stress does have a negative effect on the body's ability to heal; is there anything I can do to help you minimize the stress you feel?A client admitted for an abdominal hysterectomy reports that she has been under a lot of stress since the death of her mother and wonders how that will affect her surgery and recovery. Which of the following nursing interventions reflects the most therapeutic understanding of the relationship stress has on the body and its ability to recover from surgery? a. Suggest a demonstration of relaxation techniques b. Arrange for the hospital chaplain to visit the client c. Offer to call and get an order for an anti-anxiety medication d. Share a personal antidote concerning a similarly stressful situationa. Suggest a demonstration of relaxation techniquesThe nurse is providing care for a client who postoperatively has developed an infected incisional wound and is depressed and anorexic. Which of the following nursing interventions has priority? a. Sterile wound care b. Frequent small meals c. Administration of antidepressant medication d. Educating the client regarding wound care at homea. Sterile wound careThe nurse is educating a client diagnosed with type 2 diabetes, who is susceptible to foot wounds, on how to minimize the risk for infection related to poor wound healing by not being a susceptible host. The most appropriate suggestion would be to: a. Inspect feet and legs daily for skin breakdown b. See a podiatrist regularly for appropriate foot care c. Keep blood sugar levels within normal range to maximize the ability to heal d. Eat well-balanced meals in order to provide the nutrients necessary for healingd. Eat well-balanced meals in order to provide the nutrients necessary for healingFor infectious organisms to grow and multiply enough to cause illness, they need an environment that has appropriate amounts of: (Select all that apply.) a. Food b. Space c. Water d. Oxygen e. Warmth f. Darknessa. Food c. Water d. Oxygen e. Warmth f. DarknessWhich of the following are considered portals of exit in the chain of infection? (Select all that apply.) a. A bleeding cut b. A hardy sneeze c. A kiss on the lips d. A urinary catheter e. A scraped knuckle f. A friendly handshakea. A bleeding cut b. A hardy sneeze c. A kiss on the lips d. A urinary catheter e. A scraped knuckleWhich of the following assessment data indicate the presence of a local inflammatory process? (Select all that apply.) a. Client reports being cold b. Left elbow warm to the touch c. Elevated white blood cell (WBC) count d. Pitting edema of +2 around the right ankle e. Client reports knee pain of 5 on a scale of 1 to 10 f. Client observed grimacing while raising shoulder to brush hairb. Left elbow warm to the touch d. Pitting edema of +2 around the right ankle e. Client reports knee pain of 5 on a scale of 1 to 10 f. Client observed grimacing while raising shoulder to brush hairA client has developed pneumonia, and his temperature has increased to 37.7 C. The client is shivering and feels uncomfortable. The nurse should: a. Apply hot packs to the axilla and groin b. Wrap the clients four extremities c. Restrict oral fluid consumption d. Apply a hypothermia mattressc. Restrict oral fluid consumptionThe client comes to the emergency department after having been in the sun for an extended period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected and the nurse observes for: a. Diaphoresis b. Confusion c. Temperature of 36 C d. Decreased heart rateb. ConfusionA construction worker is seen in the emergency department with low blood pressure, normal pulse rate, diaphoresis, and weakness. These are clinical signs of: a. Heatstroke b. Heat cramp c. Hypothermia d. Heat exhaustiond. Heat exhaustionA 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to: a. Take the rectal temperature b. Take the oral temperature as planned c. Have the child rinse out the mouth with warm water d. Wait 20 minutes before assessing the oral temperatured. Wait 20 minutes before assessing the oral temperatureThe client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include: a. Replacement of fluid and electrolytes b. Initiation of oral antibiotic therapy c. Application of hypothermia wraps d. Alcohol sponge bathsa. Replacement of fluid and electrolytesThe appropriate site for taking the pulse of a 2-year-old is: a. Radial b. Apical c. Femoral d. Pedalb. ApicalThe client appears to be breathing faster than before. The nurse should: a. Ask the client if he has felt stressful b. Have the client lay down on the bed c. Count the clients rate of respirations d. Palpate the clients own radial pulsec. Count the clients rate of respirationsA nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurses most appropriate action is to: a. Give the medication b. Ask if the client is anxious c. Check the clients dressing for bleeding d. Recheck the clients vital signs in 30 minutesa. Give the medicationThe client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be: a. 10 to 40 mm Hg higher than in the brachial artery b. 20 to 30 mm Hg lower than in the brachial artery c. 40 to 50 mm Hg higher than in the brachial artery d. Essentially the same as that in the brachial arteryd. Essentially the same as that in the brachial arteryAn 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age? a. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min b. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min c. BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min d. BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/mina. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/minThe student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are: a. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg b. P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg c. P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg d. P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hgc. P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm HgThe nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age: a. T = 37.4 C b. P = 110 beats/min c. R = 20 breaths/min d. BP = 120/76 mm Hgb. P = 110 beats/minWhen using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to: a. Hold the thermometer at the bulb end b. Cleanse the thermometer in hot water c. Assess the thermometer for 5 minutes d. Allow the child to hold the thermometerc. Assess the thermometer for 5 minutesThe postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should: a. Retake the vital signs in 30 minutes b. Continue with care as planned c. Administer a stimulant d. Notify the physiciand. Notify the physicianA client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, I feel dizzy. The nurse should: a. Go for help b. Take the clients blood pressure c. Assist the client into a sitting position d. Tell the client to take several deep breathsc. Assist the client into a sitting positionA false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant: a. Wraps the cuff too loosely around the arm b. Deflates the blood pressure cuff too quickly c. Repeats the blood pressure assessment too soon d. Presses the stethoscope too firmly in the antecubital fossaa. Wraps the cuff too loosely around the armThe client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include: a. An alcohol and water bath b. Ice packs to the axillae and groin c. Tepid, plain water sponge down d. Application of a cooling blanketd. Application of a cooling blanketThe nurse is alert to which of the following factors that lowers the blood pressure? a. Stress-producing anxiety b. Heavy alcohol consumption c. Cigarette, cigar, or pipe smoking d. Prescribed diuretic administrationd. Prescribed diuretic administrationWhile the nurse is taking the clients blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is: a. 120/70 mm Hg b. 130/84 mm Hg c. 120/78 mm Hg d. 118/80 mm Hgb. 130/84 mm HgAfter measuring the clients vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5 C. The nurse should: a. Retake the blood pressure b. Retake the clients temperature c. Report all of the findings immediately d. Record the findings as within normal limitsa. Retake the blood pressureThe client is identified by the nurse as having a remittent fever. The student asks what that means and the nurse explains that a remittent fever is: a. A constant body temperature above 100.4 F with little fluctuation b. Spikes that are interspersed with normal temperatures within 24 hours c. Spikes and falls in temperature, but temperature does not return to the normal limits d. Periods of febrile episodes interspersed with normal body temperaturesc. Spikes and falls in temperature, but temperature does not return to the normal limitsThe nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the: a. Oral site b. Rectal site c. Axillary site d. Tympanic sitec. Axillary siteA client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by: a. The placement of the sensor on the extremity b. A diagnosis of peripheral vascular disease c. A reduced amount of artificial light in the room d. The increased ambient temperature of the clients roomb. A diagnosis of peripheral vascular diseaseAn individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to respond to questions. The nurse instructs the individual who has called to have the victim: a. Take sips of brandy b. Drink a bowl of warm soup c. Drink a cup of very hot coffee d. Run the affected extremities under hot waterb. Drink a bowl of warm soupA spouse assists the nurse evaluating the measurement of the clients blood pressure. The nurse feels additional teaching is required if the spouse is observed: a. Deflating the cuff at 2 mm Hg/second b. Having the client sit down for the measurement c. Using the same time each day for the measurement d. Taking the blood pressure after the client comes back from a walkd. Taking the blood pressure after the client comes back from a walkThe nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the: a. Popliteal fossa behind the knee b. Inner side of the ankle below the medial malleolus c. Top of the foot between the extension tendons of the great toe d. Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spinea. Popliteal fossa behind the kneeThe clients apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the: a. Second to third intercostal space b. Third to fourth intercostal space c. Fourth to fifth intercostal space d. Fifth to sixth intercostal spacec. Fourth to fifth intercostal spaceThe nurse enters the room to measure the clients pulse rate. The nurse recognizes that the clients rate may be increased as a result of: a. A febrile condition b. Administration of digoxin c. The clients athletic conditioning d. Unrelieved severe postoperative paina. A febrile conditionUpon entering the room, the nurse notes that the client has an irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse reports this respiratory assessment as: a. Biots respirations b. Kussmauls respirations c. Hyperpneic respirations d. Cheyne-Stokes respirationsd. Cheyne-Stokes respirationsThe nurse has assigned the vital signs of the elderly clients residing in the facility's assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN? a. As you age your blood pressure may go up, but it doesn't have to if your vessels are healthy. b. If anyones oral temperature is over 100 F, I'll let you know right away since that means they have a fever. c. I always wait a good 30 minutes after returning the older client back to bed before I count their pulse. d. I watch the elderly clients stomach and count the number of times it rises when I am counting respirations.b. If anyones oral temperature is over 100 F, I'll let you know right away since that means they have a fever.The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients? a. A 25-year-old who was admitted for depression and anxiety b. A 69-year-old diagnosed with Parkinson's disease 5 years ago c. A 57-year-old prescribed antihypertensive medication 6 weeks ago d. An 80-year-old client whose systolic BP is routinely assessed in the low 90sb. A 69-year-old diagnosed with Parkinson's disease 5 years agoThe nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients? a. A 25-year-old who was admitted for alcohol detoxification b. A 69-year-old diagnosed with Parkinson's disease 5 years ago c. A 57-year-old placed on antihypertensive medication therapy 2 months ago d. An 80-year-old client whose systolic BP is routinely assessed in the high 80sa. A 25-year-old who was admitted for alcohol detoxificationThe nurse has assigned nursing assistive personnel to obtain the blood pressures on the units clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings? a. I'll ask the clients what their blood pressure usually runs. b. I'll give you a list of all the readings I get before I chart them. c. I'll chart the results and let you know whose pressure is high. d. I'll recheck any pressure that seems higher than their normal.b. I'll give you a list of all the readings I get before I chart them.The nurse has assigned nursing assistive personnel to obtain the blood pressures on the units clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings? a. I'll give you a list of all the readings after I chart them. b. May I ask the clients what their blood pressure usually runs? c. I'll chart the results and let you know whose pressure is running high. d. Do you want me to take the readings before they get their medications?c. I'll chart the results and let you know whose pressure is running high.The nurse has assessed a clients blood pressure (BP) using the left thigh because of bilateral upper arm casts. The clients precasting left arm BP was 108/70 mm Hg. The nurse expects the present BP reading to be: a. 10-40 mm Hg higher systolic pressure than before the casting b. 5-10 mm Hg higher reading in both systolic and diastolic pressures c. Representative of the original baseline established before the casting d. A slight decrease in the diastolic pressure when compared to precasting pressurea. 10-40 mm Hg higher systolic pressure than before the castingThe nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately? a. Review the clients chart for his last blood pressure reading. b. Ask the client what his typical blood pressure reading is when taken manually. c. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated. d. Take the clients blood pressure both sitting and standing and use the higher reading.c. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated.The nurse is assessing an elderly clients blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the clients pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation is: a. The difference between the monitoring equipment being used b. The client may be experiencing mild anxiety regarding the check-up c. The effects of aging on the clients ability to hear the first Korotkoff sound d. The client is not inflating the cuff sufficiently to detect the systolic pressureb. The client may be experiencing mild anxiety regarding the check-upThe nurse is assessing a clients blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data: a. Reflect a normal variation b. Should be reported to the clients health care provider c. Dictate that pressure should be monitored in the left arm d. Indicate that the client may be experiencing vascular problemsb. Should be reported to the clients health care providerThe nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke? a. A 34-year-old running for the first time in the July 4th marathon who is sweating profusely b. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate c. A 75-year-old who is prescribed medication for Crohns disease and who is sitting outdoors watching her granddaughter run the marathon d. A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon courseb. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gateThe nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke? a. The 75-year-old who has forgot where the car is parked b. The 16-year-old volunteer whose skin appears sunburned but dry c. The 34-year-old who finished the race and is reporting leg cramps d. The 55-year-old observer who complains of nausea and being thirstyb. The 16-year-old volunteer whose skin appears sunburned but dryThe nurse has assigned nursing assistive personnel to obtain the temperatures on the units clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally? a. Are all the clients cooperative enough to take the temperatures orally? b. Do you want me to take the temperature tympanically on everyone? c. I'll wait until breakfast is over so I wont distract them from eating. d. I'll chart the results and let you know whose temperature is running high.c. I'll wait until breakfast is over so I wont distract them from eating.Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)? a. A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds b. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds c. The ring finger of a client with Parkinson's disease that has a capillary refill time of less than 3 seconds d. An earlobe of a client who is experiencing moderate diaphoresis with a nail capillary refill time of 3.5 secondsb. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 secondsThe nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago. Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client? a. Is there anything affecting her right arm? b. Has she been experiencing any edema in that left arm? c. How long has it been since she had her breast removed? d. I'll wait until she's been medicated for pain before I take it.a. Is there anything affecting her right arm?The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that apply.) a. At the same time each day b. On the same arm each time c. In the same position each time d. After the client has had a brief rest e. After his blood pressure medication f. Right before getting up in the morninga. At the same time each day b. On the same arm each time c. In the same position each time d. After the client has had a brief restWhich of the following factors make using a pulse oximeter on an elderly client challenging? (Select all that apply.) a. Possibility of decreased cardiac output b. Potential for peripheral vascular disease c. Existence of decreased red blood cell count d. Uncooperative behavior related to senility e. Inability to comprehend rationale for monitoring f. Vasoconstriction related to impaired heat regulationa. Possibility of decreased cardiac output b. Potential for peripheral vascular disease c. Existence of decreased red blood cell count f. Vasoconstriction related to impaired heat regulationThe nurse is providing a health promotion session regarding the factors that contribute to heatstroke for members of a college cross-country running team. Which of the following statements should the nurse include in the discussion? (Select all that apply.) a. Take frequent breaks to rest out of the sun. b. The greater the humidity, the greater the hazard. c. Wear clothing that will absorb the perspiration. d. The higher the temperature, the higher the risk. e. The more fluids you drink, the fewer chances you take. f. Pay attention to pacing yourself when it's hot and muggy.b. The greater the humidity, the greater the hazard. d. The higher the temperature, the higher the risk. e. The more fluids you drink, the fewer chances you take. f. Pay attention to pacing yourself when it's hot and muggy.The nurse is discussing risk factors for hypertension with family members attending a self-help group meeting for clients in cardiac rehabilitation. Which of the following statements made by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.) a. Low fat foods are your blood pressures best friend. b. Have your triglycerides checked on a regular basis. c. Ideal weight is ideal for keeping blood pressure under control. d. Nicotine is a no-no when attempting to control blood pressure. e. If they are prescribed, take your blood pressure medicine as suggested. f. Keep alcohol consumption down and your blood pressure will be down.a. Low fat foods are your blood pressures best friend. b. Have your triglycerides checked on a regular basis. c. Ideal weight is ideal for keeping blood pressure under control. d. Nicotine is a no-no when attempting to control blood pressure. f. Keep alcohol consumption down and your blood pressure will be down.The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers. Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.) a. The cuff cannot be too small or too big. b. Don't release the air out of the cuff too quickly. c. Keep the arm you are using at the level of the heart. d. If you are having difficulty, try taking it in the other arm. e. The stethoscope needs to be placed directly over a pulse point. f. Remember to pump up the cuff until you can no longer feel the pulse.a. The cuff cannot be too small or too big. b. Don't release the air out of the cuff too quickly. e. The stethoscope needs to be placed directly over a pulse point. f. Remember to pump up the cuff until you can no longer feel the pulse.The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.) a. Slowly deflate the pressure from the cuff. b. Wrap the cuff snuggly around the clients arm. c. Always support the clients arm at the level of the heart. d. Be sure that the cuff is wide enough for the clients arm. e. Allow the arm to rest before repeating the blood pressure. f. Make sure your stethoscope is fitted in your ears appropriately.b. Wrap the cuff snuggly around the clients arm. c. Always support the clients arm at the level of the heart. d. Be sure that the cuff is wide enough for the clients arm. e. Allow the arm to rest before repeating the blood pressure.Which one of the following nursing interventions for a client in pain is based on the gate-control theory? a. Giving the client a back massage b. Changing the clients position in bed c. Giving the client a pain medication d. Limiting the number of visitorsa. Giving the client a back massageA priority nursing intervention when caring for a client who is receiving an epidural infusion for pain relief is to: a. Use aseptic technique b. Label the port as an epidural catheter c. Monitor vital signs every 15 minutes d. Avoid supplemental doses of sedativesc. Monitor vital signs every 15 minutesThe nurse should describe pain that is causing the client a burning sensation in the epigastric region as: a. Referred b. Radiating c. Deep or visceral d. Superficial or cutaneousc. Deep or visceralWhich of the following is most appropriate when the nurse assesses the intensity of the clients pain? a. Ask about what precipitates the pain. b. Question the client about the location of the pain. c. Offer the client a pain scale to objectify the information. d. Use open-ended questions to find out about the sensation.c. Offer the client a pain scale to objectify the information.The nurse on a postoperative care unit is assessing the quality of the clients pain. In order to obtain this specific information about the pain experience from the client, the nurse should ask: a. What does your discomfort feel like? b. What activities make the pain worse? c. How much does it hurt on a scale of 0 to 10? d. How much discomfort are you able to tolerate?a. What does your discomfort feel like?When a clients husband questions how a patient-controlled analgesia (PCA) pump works, the nurse explains that the client: a. Has control over the frequency of the intravenous (IV) analgesia b. Can choose the dosage of the drug received c. May request the type of medication received d. Controls the route for administering the medicationa. Has control over the frequency of the intravenous (IV) analgesiaAn older client with mild musculoskeletal pain is being seen by the primary care provider. The nurse anticipates that treatment of this clients level of discomfort will include: a. Fentanyl b. Diazepam c. Acetaminophen d. Meperidine hydrochloridec. AcetaminophenBefore inserting a Foley catheter, the nurse explains that the client may feel some discomfort. This is an example of: a. Distraction b. Reducing pain perception c. Anticipatory response d. Self-care maintenancec. Anticipatory responseThe nurse knows that a PCA pump would be most appropriate for the client who: a. Has psychogenic discomfort b. Is recovering after a total hip replacement c. Experiences renal dysfunction d. Recently experienced a cerebrovascular accident (stroke)b. Is recovering after a total hip replacementA client with chronic back pain has an order for a transcutaneous electrical nerve stimulation (TENS) unit for pain control. The nurse should instruct the client to: a. Keep the unit on high b. Use the unit when pain is perceived c. Remove the electrodes at bedtime d. Use the therapy without medicationsb. Use the unit when pain is perceivedThe nurse caring for a terminally ill client with liver cancer understands which of the following goals would be most appropriate? a. Increasingly administer narcotics to oversedate the client and thereby decrease the pain. b. Continue to change the analgesics until the right narcotic is found that completely alleviates the pain. c. Adapt the analgesics as the nursing assessment reveals the need for specific medications. d. Withhold analgesics because they are not being effective in relieving discomfort.c. Adapt the analgesics as the nursing assessment reveals the need for specific medications.A client is having severe, continuous discomfort from kidney stones. Based on the clients experience, the nurse anticipates which of the following findings in the clients assessment? a. Tachycardia b. Diaphoresis c. Pupil dilation d. Nausea and vomitingd. Nausea and vomitingNurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct? a. The client is the best authority on the pain experience. b. Chronic pain is mostly psychological in nature. c. Regular use of analgesics leads to drug addiction. d. The amount of tissue damage is accurately reflected in the degree of pain perceived.a. The client is the best authority on the pain experience.A non-pharmacological approach that the nurse may implement for clients experiencing pain that focuses on promoting pleasurable and meaningful stimuli is: a. Acupressure b. Distraction c. Biofeedback d. Hypnosisb. DistractionWhich of the following is the most appropriate nursing intervention for a client who is receiving epidural analgesia? a. Change the tubing every 48 to 72 hours. b. Change the dressing every shift. c. Secure the catheter to the outside skin. d. Use a bulky occlusive dressing over the site.c. Secure the catheter to the outside skin.The client is experiencing breakthrough pain while receiving opioids. An order is written for the client to receive a transmucosal fentanyl unit. In teaching about this medication, the nurse should instruct the client to: a. Swab the unit over the cheeks b. Do not chew the unit after administration c. Take no more than two units per episode of discomfort d. Allow the unit to dissolve slowly in the mouth over 15 minutes or moreb. Do not chew the unit after administrationWhen caring for a client who is experiencing continuous severe pain, the nurse should expect that the pain management plan would include: a. Focusing on intramuscular administration of analgesics b. Waiting for pain to become more intense before administering opioids c. Administering opioids with nonopioid analgesics for severe pain experiences d. Administering large doses of opioids initially to clients who have not taken the medications beforec. Administering opioids with nonopioid analgesics for severe pain experiencesWhich of the following symptoms would the nurse expect with a client who is experiencing acute pain? a. Bradycardia b. Bradypnea c. Diaphoresis d. Decreased muscle tensionc. DiaphoresisWhich of the following statements made by a nurse shows the greatest understanding of the personal nature of the pain experience? a. I have experienced pain before, and so I have great compassion for anyone dealing with pain. b. People handle pain differently, but everyone in pain is only interested in having the pain stop. c. Managing a clients pain is the single most important thing a nurse can do for a client experiencing pain. d. I can only accept what the client reports concerning the pain being felt and attempt to intervene successfully in its management.d. I can only accept what the client reports concerning the pain being felt and attempt to intervene successfully in its management.Which of the following statements made by a nurse requires follow-up with additional instruction regarding the personal nature of pain? a. I have experienced pain before, and so I have great compassion for anyone dealing with pain. b. My postsurgical clients get the prescribed pain medications on schedule with no diversion from that schedule. c. If I were experiencing severe pain, I certainly would want someone to devote their time to managing for me. d. Clients don't always request pain medication, and so I always ask them if they want it according to the schedule.b. My postsurgical clients get the prescribed pain medications on schedule with no diversion from that schedule.Which of the following statements made by a client reporting severe pain expresses the most insight into how pain impacts a clients energy reserves? a. I cant sleep if I don't get something for this pain. b. If only I could get an hour when I was free of this pain. c. Im exhausted physically and emotionally trying to live with this pain. d. I don't see how I can continue to cope with this pain; I need some relief.c. Im exhausted physically and emotionally trying to live with this pain.Which of the following statements made by a nurse caring for a client reporting severe pain expresses the most insight into how pain impacts a clients energy reserves? a. If I cant get his pain under control, his recovery will take a lot longer. b. Pain certainly interferes with the clients ability to rest and recuperate. c. Im going to call for another pain prescription so he can get some rest. d. Trying to cope with pain is using up the energy that his recovery requires.d. Trying to cope with pain is using up the energy that his recovery requires.Which of the following statements made by the nurse regarding the clients self-assessment of pain requires immediate follow-up regarding the personal nature of pain? 1 The medication should be providing enough relief; try to ambulate her. 2 Ive never known anyone to have such pain after that procedure. 3 He should be able to ambulate with only minimal pain by now. 4 She says she's in pain, but she doesn't act like she is in pain.4 She says she's in pain, but she doesn't act like she is in pain.The nurse recognizes that the most likely reason a runner who has injured his ankle during a race is not aware of it until after he crosses the finish line is that: a. The emotional exhilaration of running the race masked the pain of the injury b. His endorphin levels were high as a result of the physical stressors of the race c. He was mentally distracted by the need to concentrate on the ever-changing nature of the race d. The physical effects of the injury slowly increased during the race and reached pain-producing capacity only after the raceb. His endorphin levels were high as a result of the physical stressors of the raceWhich of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function? a. His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working. b. Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines. c. If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain. d. Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure.a. His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working.A client with a history of chronic back pain is questioning the need to keep asking for pain medication, fearing that he will be viewed as being weak by his family. The most therapeutic nursing response to this client would be: a. Chronic back pain is very difficult to deal with; utilize the pain medication because thats what its there for. b. Your family wont think you're weak; they want you to be comfortable, and the medication will help. c. Taking the medication as prescribed will help you to be more active; your family will be happy you can do things with them again. d. It's important that you manage your pain as effectively as possible; it really doesn't matter what other people think about you.c. Taking the medication as prescribed will help you to be more active; your family will be happy you can do things with them again.A client who is scheduled for the second in a series of painful dressing changes asks for my pain medication now so its working when the dressing is changed is most likely expressing: a. A great fear of the expected pain b. A need to be in control of his pain c. An understanding that it is easier to prevent the pain than to stop the pain d. An acceptance of the pain that the dressing change will obviously cause himc. An understanding that it is easier to prevent the pain than to stop the painThe nurse inquires of a postoperative client as to the need for pain medication. The client denies the need then but 30 minutes later reports, I am really in a lot of pain. Can you bring me my pain pill now? The nurse recognizes that the most immediate need for client education is related to explaining that: a. His oral medication will take approximately 30 minutes to affect his pain b. There may be a need to administer his pain medication via the intravenous route c. Pain medication is more effective if blood levels are maintained at a constant level d. His pain will be more effectively managed if he reports a need for pain medication while the pain is still tolerabled. His pain will be more effectively managed if he reports a need for pain medication while the pain is still tolerableThe nurse is caring for a cognitively impaired client who has experienced a painful procedure. The nurse is most effective in determining the clients pain medication needs when using which of the following assessment methods? a. Medicating the client with the as-needed (prn) analgesic as often as ordered b. Utilizing the pain face scale to assess the clients pain experience c. Asking the client to rate his or her pain on a scale of 1 to 10, with 10 being the most severe pain d. Observing the clients body movements and facial expressions for typical pain behaviorsd. Observing the clients body movements and facial expressions for typical pain behaviorsThe nurse is attempting to ambulate a postoperative client who continues to rate his pain as a 7 on a scale of 0 to 10, with 10 being the most severe. The client is reluctant to walk and consents to move only to the chair, reporting that it hurts too much to walk. The nurses primary concern regarding the clients recovery related to his pain experience is that: a. His pain medications are not effectively managing his pain b. He does not fully understand the importance of ambulation c. He is expending too much of his energy dealing with the pain d. He is not ready to participate in the activities needed to recover quicklyd. He is not ready to participate in the activities needed to recover quicklyThe nurse is attempting to ambulate an older adult client who recently experienced a fall at the assisted living facility where he resides. The client is reluctant to walk and consents to move only to the chair, reporting that it hurts too much to walk. Which of the following nursing interventions is most therapeutic regarding this client? a. Allow the client to remain in bed in order to conserve his energy. b. Transfer him to the chair, realizing some activity is preferable to none. c. Call his health care provider to discuss the apparent ineffectiveness of his pain medications. d. Assess the client for other factors that may be affecting his ability and motivation to ambulate.d. Assess the client for other factors that may be affecting his ability and motivation to ambulate.A client with chronic pain states, I just want to be pain-free. Do something to make that happen. The most therapeutic response is: a. Together we will all work at making your pain tolerable. b. I will do everything I can to manage your pain; I promise. c. Are you feeling depressed or anxious because of your pain? d. You sound anxious. Would you like something for your nerves?a. Together we will all work at making your pain tolerable.The greatest barrier to a 3-year-old clients ability to self-assess her pain is: a. A limited vocabulary b. Increased separation anxiety c. Reluctance to talk to strangers d. Inability to grasp the concept of paina. A limited vocabularyThe nurse is discussing the effects of pain with an older adult client diagnosed with osteoarthritis. The most therapeutic response to the clients comment of, I wonder whether it would hurt if I took a nap in the afternoon? would be: a. As long as it did not interfere with your getting a good nights sleep. b. Id suggest taking your nap right after you take your pain medication. c. If it helps you cope better with the pain, I don't see any harm in taking a nap. d. I think a nap is a good idea because we seem to feel pain more when we are tired.d. I think a nap is a good idea because we seem to feel pain more when we are tired.Which of the following statements is the most appropriate response to a clients statement, I thought you could tell I was in pain? a. How do you express a need for pain medication if not by asking? b. I'm so very sorry; may I get you your pain medication right now? c. I don't think its wise to assume I can effectively read your mind regarding the need for pain medication. d. I will make a point of asking you to rate your pain at least every 2 hours, so this miscommunication wont happen again.d. I will make a point of asking you to rate your pain at least every 2 hours, so this miscommunication wont happen again.A 44-year-old client shares with the admitting nurse that the client is having epigastric pain that the client identifies as a 7 on a 0 to 10 scale. In order to plan for the pain management of this client, which is the most appropriate response from the nurse? a. What would be a satisfactory level of pain control for us to achieve? b. You don't look like you're in that much pain. c. You'll be pain-free following your surgery. d. I've cared for a client with a nail in his head who only rated his pain as a 5; are you sure your pain is a 7?a. What would be a satisfactory level of pain control for us to achieve?The home care nurse notes that a 67-year-old female diabetic clients blood glucose level has been elevated since she strained her back the previous week. The client states that she cannot understand why her blood glucose level is elevated. The nurse suspects the most likely cause for the elevated blood sugar is: a. The decreased activity level of the client since the injury b. Parasympathetic stimulation from the body's normal response to pain c. The client is consuming more food as a comfort measure d. The client may not be taking her medication as orderedb. Parasympathetic stimulation from the body's normal response to painA client with chronic pain presents in the emergency department of the local hospital stating I just cant take this anymore. On questioning the client, the nurse discovers that the client have experienced chronic pain since being involved in an accident 2 years previously. The client states that he has been labeled a drug seeker because he is looking for relief for the pain and feels hopeless, angry, and powerless to do anything about the situation. The nurse understands that this client is at risk for: a. Criminal activity b. Opioid abuse c. Suicide d. Drug addictionc. SuicideA client who had knee replacement surgery the previous day refuses to take any pain medication, even though he rates his pain as an 8 on a 0 to 10 scale. Upon questioning the client the nurse learns that the reason for refusing pain medication is because he is concerned about injuring the knee and not feeling it. The best information that the nurse can provide this client is to explain that: a. The pain medication will help speed his recovery time b. He need not worry about becoming addicted to the pain medication c. He will not be perceived as weak for taking the pain medication d. He is being a difficult client and needs to comply with the health care providers ordersa. The pain medication will help speed his recovery timeA 38-year-old client presents to the pain clinic with complaints of phantom pain. The client was involved in a farming accident 3 years previously that resulted in a below-the-elbow amputation of his right arm. The nurse knows that phantom pain is categorized as: a. Painful polyneuropathy b. Somatic pain c. Sympathetically maintained pain d. Deafferentation paind. Deafferentation painThe daughter of an 88-year-old female client tells the nurse that her mother has recently quit going on walks in the neighborhood because of pain in her legs. Which of the following is the best response from the nurse? a. I would like to speak with your mother to get more information. b. Older people frequently suffer from arthritis that can cause leg pain. c. Your mother probably has poor circulation in her legs, which is causing the pain. d. She is lucky to be as healthy as she is at her age.a. I would like to speak with your mother to get more information.The nursery nurse is explaining post-circumcision care to a new mother. Which of the following statements by the new mother indicates that additional teaching needs to occur? a. Babies don't experience pain, so I don't need to worry about hurting him when I touch the penis. b. I need to be careful not to put his diaper on too tight to avoid discomfort. c. I can comfort my baby following the procedure by holding him. d. The health care provider will numb the area before performing the procedure.a. Babies don't experience pain, so I don't need to worry about hurting him when I touch the penis.Taking into consideration the hospice clients chronic pain from bone cancer, the most appropriate person to collaborate with regarding management of pain is: a. Occupational therapist to devise a splint for the clients leg b. Physical therapist to determine exercises to strengthen the leg muscles c. Art therapist to provide creative therapy as a diversion d. An oncology nursed. An oncology nurseIn creating the plan of care for a newly diagnosed breast cancer client, the nurse is concerned about pain control. The client has expressed an interest in relaxation therapy as a complementary pain therapy. The nurse knows that the best time to teach the client is: a. Immediately following the clients mastectomy b. Before giving pain medication to evaluate if the complementary therapy works c. Immediately preceding surgery d. When the client is comfortabled. When the client is comfortableA client who ruptured his spleen in a motor vehicle accident rates his postoperative pain as a level 8 on a 0 to 10 pain scale. After administering pain medication, the nurse discusses the use of complementary therapies with the client to explore ways to reduce the pain. The client would like to try a massage. The nurse delegates this task to the assistive personnel (AP). Which of the following instructions is most important for the nurse to share with the AP? a. You need to warm the bottle of lotion before using it. b. Report any changes in the clients skin condition to me immediately. c. Do not massage the clients legs. d. Massage each body part at least 10 minutes.c. Do not massage the clients legs.Which of the following client outcomes reflect the positive aspects of effective pain management? (Select all that apply.) a. The client with arthritis in both hands knitting for pleasure b. A client rating his chronic back pain as a 3 on a scale of 0 to 10 c. A client with type 2 diabetes walking 5 miles in a Fourth of July parade d. A client who has undergone surgery ambulating to the bathroom on the first postoperative day e. A client with knee replacement surgery returning to his job as a mail carrier f. A client with terminal cancer going home on outpatient chemotherapya. The client with arthritis in both hands knitting for pleasure b. A client rating his chronic back pain as a 3 on a scale of 0 to 10 d. A client who has undergone surgery ambulating to the bathroom on the first postoperative day e. A client with knee replacement surgery returning to his job as a mail carrier f. A client with terminal cancer going home on outpatient chemotherapyThe nurse recognizes which of the following client outcomes as being a result of ineffective pain management? (Select all that apply.) a. Client expressing feelings of despair and hopelessness b. Inability to self-ambulate distance from bed to bathroom c. Stage 1 pressure ulcer development on coccyx and left hip d. Client rating pain as 4 on a scale of 0 to 10 30 minutes after pain medication e. Postponement of discharge because of the inability to perform activities of daily living f. Postponement of physical therapy because of clients inability to tolerate knee flexiona. Client expressing feelings of despair and hopelessness b. Inability to self-ambulate distance from bed to bathroom c. Stage 1 pressure ulcer development on coccyx and left hip e. Postponement of discharge because of the inability to perform activities of daily living f. Postponement of physical therapy because of clients inability to tolerate knee flexionWhich of the following outcomes are directly related to functional impairment of the older client experiencing pain? (Select all that apply.) a. Inability to prepare food to meet nutritional requirements b. Inability to exit home quickly in the case of a fire c. Development of skin breakdown on buttocks d. Development of an irregular heart rhythm e. Displaying signs of clinical depression f. Feeling alone, unloved, and forgottena. Inability to prepare food to meet nutritional requirements b. Inability to exit home quickly in the case of a fire c. Development of skin breakdown on buttocks e. Displaying signs of clinical depression f. Feeling alone, unloved, and forgottenA nurse is performing hand hygiene after caring for a client who ha Clostridium difficile. Which of the following h and hygiene methods should the nurse use? A. Alcohol-based sanitizer B. Soap and water C. Iodine Solution D. Chlorhexidine solutionB. Soap and WaterA nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves? A. After donning a gown and before collecting vital signs on the client B. After removing food items off the client's tray and before removing soiled linens from the client's bed C. After helping the client stand up and before helping them brush their teeth D. After changing a dressing on the client and before documenting findings on a computerDA nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?B. Report needlestick injuries to the nursing supervisorA nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infectionC. Susceptible hostA nurse is assisting in providing an in service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?A. AirborneA nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory test?A. C-reactive proteinA nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?B. Place the client in a private roomA nurse is assisting with teaching a newly licensed nurse about surgical asepsis. which of the following statements should the nurse make?D. "Remove nail polish on your fingernails if it is chippedA nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?D. AirborneA nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAURIs). Which of the following interventions should the nurse include in the bundle?A. Try to use alternatives before inserting indwelling urinary cathetersA nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?B. Turns off the faucet with a towel.A nurse is planning to admit a client who has respiratory syncytial virus. Which of the following precautions should the nurse plan to implement?C. DropletA nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection?B. ConvalescenceA nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?B. DropletA nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?C. Gloves should be removed from the inside outA nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?C. Apply chlorhexidine and ethanol to the handsA nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). which of the following information should the nurse include?A. The door to the AIIR should remain closedA nurse is setting up a sterile field to perform a dressing change on a client. which of the following actions should the nurse take?A. Open the first flap on the sterile package away from their bodyA nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?A. DropletA nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?C. BacteriaA nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent?A. ReservoirA nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?D. ProdromalA nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove firstB. GlovesA nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?B. ContactA nurse is performing a throat culture on a client. Which of the following actions should the nurse take?A. Swab the back of the client's pharyngeal wallA nurse is preparing to obtain a young adult clients apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the clients pulse? a) Apex of the heart b) right side of sternum c) 4th intercostal space d) Midclavicular line below right clavicleApex of the heartA nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. Which of the following clients should the nurse identify as requiring further data collection due to bradycardia?a young adult client who has a radial pulse rate of 56/minA nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse?The AP informs the client when they are counting the respirations.A nurse is assisting in the planning of an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse recommend be included?A temporal probe thermometer uses infrared scanning to determine a clients temperatureA charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching?recording vital signs provides critical information regarding a clients condition.A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP?A client who was recently admitted and reports chest painA nurse is reviewing the vital signs obtained by an assistive personnel at 1200. for which of the following clients should the nurse plan to intervene?Toddler who has a respiratory of 44/minA nurse is working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider?a client who has an apical pulse rate of 120/minA nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first?A 52-year-old client who has a SaO2 of 92%A nurse is providing care to a client who has a apical pulse rate of 54/min and is experiencing dizziness. which of the following is the nurse's priority action?inform the client to ask for the assistance with getting out of bed.A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. which of the following factors should the nurse include in their response?smokingA nurse is contributing to the plan of care for a client who is experiencing tachycardia. Which of the following intervention should the nurse plan to recommend?encourage the client to the practice relaxation techniques each day.A nurse is discussing the use of a clients thigh for blood pressure measurements with an assistive personnel (AP). which of the following information should the nurse include?Use the thigh to obtain blood pressure when a client has severe edema in their arms.A nurse assisting with the in-service for a group of nurses about cardiac output. Which of the following statements should the nurse make?"cardiac output is the amount of blood flow through the heart in 1 minute."A nurse is contributing to the plan of care for a client who has a temperature of 39.1 C (102.4 F). Which of the following interventions should the nurse include?Administer an antipyretic medicationA charge nurse is discussing mechanisms of loss of body heart with a newly licenses nurse. Which of the following statements should the nurse include?" Radiation is the loss of body heat when a client is in close proximity to a cooler surface."A nurse is reviewing the vital signs of four clients. the nurse should identify that which of the following clients has a vital sign outside of the expected reference range?A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm HgA charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart?Sinoatrial (SA) nodeA charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make?" A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension"A nurse obtains a clients electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next?obtain a manual blood pressure reading from the client.A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse?Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall.A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased peripheral circulation. which of the following findings should the nurse report to the RN?left radial pulse is nonpalpableA nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention?A school-age child who has a respiratory rate of 14/minA nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include?Oxygen saturation reflects the amount of the oxygen being delivered to body tissuesA nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take?Instruct the client to bear down like they are having a bowel movementA nurse is reinforcing teaching with a group of assistive personnel (AP) about techniques used to obtain BP. for which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement?A client who has stabilized BP measurementsA nurse is contributing to the plan of care for a client who has hypertension. Which of the following interventions should the nurse recommend? ( select all that apply.)provide the client with low-sodium meals and snacks Encourage the client to participate in physical activity each day Instruct the client in the use of relaxation techniques Inform the client of the importance of abstaining from using products that contain nicotine .A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include?A client who has a blood pressure of 162/102 mm Hg has stage II hypertensionA nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse?the AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia?A young adult who has an apical pulse rate of 104/minA nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieced of documentation is correct?SaO2 97 % right index finger, room airA nurse is collecting data from a 3-month-old infant during a well-child visit. Which of the following actions should the nurse take when checking the infants apical pulse?Place the stethoscope over the 4th intercostal space to the left of the sternum.A charge nurse is evaluating a newly licensed nurses documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete?BP 124/82 mm Hg, lying in bedA nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rated. the clients auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. the nurse should document the findings as which of the followingPulse deficit of 13/minA nurse is caring for a client who has a heart rate of 118/min. which of the following actions should the nurse take to improve the clients heart rate?encourage the client to reduce intake of caffeinated soft drinksA nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. which of the following findings indicates an intervention was effective?An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min.A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up the nurse?DyspneaA nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention?A 3-year-old preschooler who has an apical rate of 144/minA charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. which of the following statements should the charge nurse include?" hypertension is diagnosed with two elevated measurements on two separate occasions."A nurse is obtaining vital signs for a group of clients. which of the following findings requires intervention?An 11-year-old child who has a respiratory rate of 34/mina nurse is planning care for a group of clients. for which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature?a client who is diaphoretic and frequently chewing ice to relive dry moutha nurse is assisting with planning an in-service about vital signs for a group of assistive personnel. which of the following information should the nurse recommend be included measuring body temperature?oral temperature is easily accessible despite a clients postionA nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. which of the following clients' vital signs indicate that interventions were effective? (select all that apply)A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm HgA nurse is caring for a client who has an increase in cardiac afterload. which of the following findings should the nurse expect.increase in blood pressurea charge nurse is reviewing the technique for obtaining Sao2 with a group of newly hired nurses. identify the order of the steps the nurse should include. ( move the steps into the box on the right, placing them in the order of performance. Use all the steps.)1. select the site for obtaining the measurement is the first step 2. apply the sensor probe on the chosen site is the second step 3. confirm the pulse rate displayed on the oximeter by palpating the radial pulse 4. wait 15 secs and observe the SaO2 percentage displayed on the pulse oximetera nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. which of the following findings requires follow up?a client has a radial pulse of +4 bilateralA nurse is reinforcing teaching about thermoregulation to a group of newly licensed nurses. which of the following statements should the nurse include in the teaching?" the body lowers body temperature through sweating"A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include?blood pressure is measured and documented in millimeters of mercuryA nurse is contributing to the planning of an in-service about factors affecting respiratory rate for a group of assistive personnel. which of the following information should the nurse recommend be included?fever can increase a clients respiratory ratea nurse is evaluating the effectiveness of interventions used to address clients vital signs that were outside of the expected reference ranges. which of the following findings indicates the intervention was effective?a young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm hg after using an inhalerA charge nurse is discussing a clients respiratory data with a newly licensed nurse. which of the following statements should the nurse include?"count the respiratory rate for 1 minute for clients who have a respiratory infection'a nurse is assisting with preparing an in-service about peripheral pulses for a group of staff nurses. which of the following information should the nurse recommend/a pulse strength of +1 indicates that the pulse is weak or diminished upon palpationa nurse is caring for a client who has hypotension. which of the following factors should the nurse identify as a contributing factor to the clients condition?decrease in contractilitya nurse is assisting with the care of a client who has orthostatic hypotension. which of the following actions should the nurse take?encourage the client to change positions slowlya nurse is caring for a client who has an increase in cardiac output. which of the following findings should the nurse expect?increase in blood pressurea nurse is reviewing blood flow through the heart with a group of assistive personnel. the nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle?pulmonary arterya nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. from which of the following clients should the nurse collect data and recheck the vital signs prior to notifying the provider?8-year-old male: respiratory rate 34/min, Sa)2 97%a nurse is reinforcing teaching with a group of newly licensed nurses about vital sign measurements. which of the following factors should the nurse include in the teaching?body temperature is typically lower in older adults.A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take? a. Tie the restraints to the siderails on the client's bed. b. Remove the restraints with each vital sign check. c. Use a square knot to secure the restraints. d. Make sure one finger can fit under the restraints.b. Remove the restraints with each vital sign check.A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? a. Extinguish the fire. b. Close the windows in the client's room. c. Close the client's door. d. Activate the fire alarm.d. Activate the fire alarm.A nurse is planning to implement the Transforming Care at the Beside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan? a. Require nurses to spend 50% of their time at the bedside of clients. b. Perform change-of-shift report at the nurses' station. c. Complete client rounds every 4 hr. d. Use a standardized communication tool.d. Use a standardized communication tool.A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for fire to occur? (Select all that apply) a. Carbon dioxide b. Nitrogen c. Cooking oil d. Oxygen e. Heatc. Cooking oil d. Oxygen e. HeatA nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take? a. Rinse the client's skin with water. b. Remove the client's clothing by pulling it over their head. c. Dispose of the client's clothing in a single biohazard bag. d. Prepare to administer potassium iodide to the client.a. Rinse the client's skin with water.A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? a. Record the time and length of the seizure. b. Restrain the client's extremities. c. Place the client in the prone position. d. Monitor the client's hemoglobin level.a. Record the time and length of the seizure.A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? a. The nurse plugs in a sequential compression device with wet hands. b. The nurse holds onto the plug to unplug a client's electronic blood pressure machine. c. The nurse rolls the client's bed over an electrical cord. d. The nurse uses an extension cord to plug in a client's smart infusion pump.b. The nurse holds onto the plug to unplug a client's electronic blood pressure machine.A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection? a. Wipe down the client's bedside table with an antiseptic wipe. b. Conduct informal audits of medical records to identify the number of healthcare-associated infections. c. Perform hand hygiene. d. Instruct the client on ways to reduce the risk for infection.c. Perform hand hygiene.A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? a. The client's full name b. The client's date of birth c. The client's telephone number d. The client's diagnosis e. The client's room numbera. The client's full name b. The client's date of birth c. The client's telephone numberA nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? SATA a. A client's visitor falls in the hallway. b. A nurse forgets their computer password. c. A client develops an unexpected reaction to a medication. d. A client's dentures are lost. e. An antibiotic was administered to a client 30 min after the scheduled time.a. A client's visitor falls in the hallway. c. A client develops an unexpected reaction to a medication. d. A client's dentures are lost.A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? a. An extension cord is secured under a rug. b. The edges of stairs are marked with brightly colored tape. c. A toaster is plugged in when not in use. d. The water heater is set to 55° C (131° F).b. The edges of stairs are marked with brightly colored tape.A nurse is assisting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include? a. Legitimate absenteeism b. Strict adherence to facility policies c. Consistent adequate work performance d. Frequent reports of not being treated fairlyd. Frequent reports of not being treated fairlyA nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? (Select all that apply) a. Influenza infection b. Catheter-associated urinary tract infection c. Mycobacterium tuberculosis infection d. Central line-associated bloodstream infection e. Surgical site infectionb. Catheter-associated urinary tract infection d. Central line-associated bloodstream infection e. Surgical site infectionA nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? a. Near-miss event b. Client safety event c. Adverse event d. Sentinel eventa. Near-miss eventA nurse is planning to use the identity, situation, background, assessment, recommendation, read back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR? a. The client's admitting diagnosis b. The client's medical history c. The client's laboratory test results d. The client's response to treatmentc. The client's laboratory test resultsA nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates understanding of the teaching? a. Locks the brakes on the client's bed b. Checks the maximum weight of the lift before using it c. Places the client on the edge of the sling d. Uses the lift without assistance from another team member e. Performs a safety check before lifting the clienta. Locks the brakes on the client's bed b. Checks the maximum weight of the lift before using it e. Performs a safety check before lifting the clientA nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? SATA a. The date the medication was mixed b. The client's age c. The client's room number d. The dose of the mixed medication e. The time the medication was mixeda. The date the medication was mixed d. The dose of the mixed medication e. The time the medication was mixedA nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include that which of the following is a hospital-acquired injury? (Select all that apply) a. Blood transfusion incompatibility b. Wrong site surgery c. Ineffective insulin usage d. Dysphagia following a stroke e. Dehydration due to diarrheaa. Blood transfusion incompatibility b. Wrong site surgery c. Ineffective insulin usageA nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (Select all that apply) a. Place the client on round-the-clock surveillance. b. Remove objects from the room that the client could use to harm themselves. c. Search items brought into the client's room by visitors. d. Refrain from asking the client if they intend to harm themselves. e. Screen the client for suicidal ideation.a. Place the client on round-the-clock surveillance. b. Remove objects from the room that the client could use to harm themselves. c. Search items brought into the client's room by visitors. e. Screen the client for suicidal ideation.A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply) a. Fall history b. Medical diagnosis c. Use of assistive devices d. Mental status e. Do-not-resuscitate statusa. Fall history b. Medical diagnosis c. Use of assistive devices d. Mental statusA nurse is teaching a client about how to perform daily blood pressure readings at home. Which of the following statements by the client is an example of the teach-back method of learning? A. "Show me again how to position the blood pressure cuff on my arm." B. "I have an electronic blood pressure machine at home that I will use." C. "I believe I can take my blood pressure successfully after talking through the steps." D. "Let me show you how I will take my blood pressure at home each day."D. "Let me show you how I will take my blood pressure at home each day."A nurse is preparinng for a teaching session with a client who has pernicious anemia. Which of the following should the nurse identify as part of the implementation step of the teaching process? A. Determine the client's health literacy. B. Develop a teaching plan that meets the client's needs. C. Use demonstration to teach the client about Vitamin B12 injections. D. Determine if the client has met the goals.C. Use demonstration to teach the client about Vitamin B12 injections.A nurse is providing teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Ask the client's family member to translate. B. Request a medical interpreter to be present. C. Ask another nurse on the unit to translate. D. Provide the client with only written materials.B. Request a medical interpreter to be present.A nurse is providing teaching about performing blood glucose checks to a client who has a new diagnosis of diabetes mellitus. Which of the following actions indicates the nurse is using the affective domain of learning? A. Ask the client how they feel about checking their blood glucose levels. B. Ask the client to demonstrate how to check their blood glucose level. C. Ask the client to verbalize the steps of checking their blood glucose level. D. Ask the client if they understand the importance of monitoring their blood glucose level.A. Ask the client how they feel about checking their blood glucose levels.A nurse is teaching a group of newly licensed nurses about client education. Which of the following information should the nurse include in the teaching? A. Documentation of the client education is not required for Joint Commission accreditation. B. Client education does not change a client's values. C. Client education does not influence the client's pain level. D. Client education can improve self-care at home.D. Client education can improve self-care at home.A nurse is preparing for a teaching session with a client. Which of the following actions should the nurse take to provide the client with unbiased care? (Select all that apply.) A. Avoid assumptions about the client. B. Compare the client to a former client. C. Ask coworkers to share their past experiences with similar clients. D. Control personal thoughts about the client. E. Collaborate with another nurse to develop teaching strategies.A. Avoid assumptions about the client. D. Control personal thoughts about the client. E. Collaborate with another nurse to develop teaching strategies.A nurse is reviewing a client's plan of care. "The client will ambulate 20 feet using a walker" is the desired outcome. Which of the following aspects of the SMART goal should the nurse identify from the outcome? A. Specific B. Timed C. Measurable D. AchievableB. TimedA nurse is reviewing information about client education with a newly licensed nurse. Which of the following information should the nurse include as the focus of client education? A. Empowering clients to be accountable for self-care. B. Providing the client with disease-oriented education. C. Providing education only to the client to protect confidentiality. D. Encouraging clients to let go of previous experiences.A. Empowering clients to be accountable for self-care.A nurse is caring for a client who has impaired cognition and has begun taking a new medication. Which of the following actions should the nurse take during client education? A. Expect the client to understand the information. B. Direct the education to the caregivers as well as the client. C. Provide written handouts only. D. Speak quickly.B. Direct the education to the caregivers as well as the client.A nurse is participating in a question-and-answer session with a client. Which of the following domains of learning uses this type of client education? A. Cognitive domain. B. Affective domain. C. Psychomotor domain. D. Adaptation domain.A. Cognitive domain.A nurse is providing teaching to a client who has a new prescription for eye drops. Which of the following teaching strategies is an example of using the psychomotor domain of learning? A. Discuss with the client how to use the eye drops. B. Encourage the client to ask questions about the medication. C. Provide the client with a handout that explains how to use the medication. D. Ask the client to teach-back about how to use the medication.D. Ask the client to teach-back about how to use the medication.A nurse educator is planning an in-service for staff nurses about psychomotor client teaching strategies. Which of the following activies requires the use of gross motor skills? (Select all that apply.) A. A client walking with crutches. B. A client using a manual wheelchair. C. Administering an intradermal injection to a client. D. Opening a client's medication bottle. E. Applying an adhesive bandage to a client's finger.A. A client walking with crutches. B. A client using a manual wheelchair.A nurse is assessing a client's health literacy prior to providing education. Which of the following actions should the nurse take? (Select all that apply.) A. Ask questions regarding the client's health care needs and concerns. B. Obtain a health history. C. Assess the client's education level. D. Perform a physical assessment. E. Use medical terminology when educating the client.A. Ask questions regarding the client's health care needs and concerns. B. Obtain a health history. C. Assess the client's education level.A nurse is using a question-and-answer session to teach a client about a diabetic diet. Which of the following outcomes is an example of cognitive learning? A. The client will be able to prepare a diabetic meal. B. The client understands a diabetic meal plan. C. The client accepts a diabetic meal plan. D. The client states, "I am never giving up my soda and candy."B. The client understands a diabetic meal plan.A nurse is planning a smoking cessation program for a client. Which of the following actions is a component of SMART outcome goals? A. Providing a reward for accomplishing the outcome. B. Providing motivation to accomplish the outcome. C. Providing a time frame to accomplish the outcome. D. Providing demonstration on how to complete the outcome.C. Providing a time frame to accomplish the outcome.A nurse is providing teaching to a client who has a recent diagnosis of pancreatic cancer. The nurse is using strategies in the affective domain of learning. Which of the following clients statements is part of the affective domain? A. "I have been crying a lot since I learned about my diagnosis. I'm worried about everything." B. "I am learning how to take my blood pressure so I can check it at home every day." C. "I understand I may lose weight because I may not feel like eating much." D. "I will take my pain medication on a schedule to prevent my pain from becoming severe."A. "I have been crying a lot since I learned about my diagnosis. I'm worried about everything."A nurse is reviewing goals of client education with a newly licensed nurse. Which of the following information should the nurse include? (Select all that apply) A. Improvement of health. B. Provide knowledge about an illness or injury. C. Relevance. D. Health promotion. E. Motivation.A. Improvement of health. B. Provide knowledge about an illness or injury. D. Health promotion.A nurse is admitting a client for surgery. Which of the following questions should the nurse ask to determine the client's health literacy level and learning needs? A. "Who will be your support person while you are in the hospital?" B. "Can you tell me what surgical procedure you are scheduled for?" C. "How do you plan to care for yourself when you go home after surgery?" D. "How comfortable are you with fillign out medical forms by yourself?"D. "How comfortable are you with fillign out medical forms by yourself?"A nurse is planning a 30-min group education class. Which of the following actions should the nurse plan to take to address various learning styles related to the domains of learning? A. Give demonstrations only. B. Provide games, discussion, and question-and-answer. C. Repeat demonstrations at the completion of class and lecture. D. Allow time for role play and demonstration.B. Provide games, discussion, and question-and-answer.A nurse is preparing to educate a client about the proper procedure for a dressing change. Which of the following indicates an understanding of Knowles's fundamentals principles of client readiness? A. The client states, "I will do it myself." B. The client has been awake all night. C. The client is engaged and alert. D. The client used to help change their partner's dressings.C. The client is engaged and alert.A nurse is orienting a newly licensed nurse to the unit. Which of the following statements by the newly licensed nurse indicates and understanding of the importance of documentation of client education? A. "Client documentation can decrease hospital reimbursement." B. "Client documentation can decrease the need to re-evaluate the client's educational needs." C. "Client documentation can increase staffing and services." D. "Client documentation can increase liability."C. "Client documentation can increase staffing and services."A nurse is discussing the nurse's role in client education with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of a nurse's role? A. "Nurses make up the greatest percentage of members of a health care team." B. "Providers make up the greatest percentage of members of a health care team." C. "Physician assistants have the greatest percentage of members on a health care team." D. "Physical therapists have the greatest percentage of members on a health care team."A. "Nurses make up the greatest percentage of members of a health care team."A nurse is evaluating a client's plan of care. The desired outcome of having the cilent sit on the side of the bed by the end of the shift was not met. Which of the following actions should the nurse take? A. Determine if different nursing interventions are required. B. Formulate a new analysis. C. Notify the health care provider. D. Notify physical therapy to assist getting the client out of bed to meet goals.A. Determine if different nursing interventions are required.A nurse is assessing a postoperative client prior to teaching a session. The nurse notes that the client is grimacing and restless. Which of the following barriers to learning is the client exhibiting? A. Psychomotor deficit. B. Depression. C. Physical discomfort. D. Lack of motivation.C. Physical discomfort.A nurse is preparing a low-stimulus environment for an education session on smoking cessation. Which of the following should the nurse implement? A. Set the thermostat to a comfortable temperature. B. Dim the lights in the room. C. Leave the door open during the educational session. D. Play relaxing music.A. Set the thermostat to a comfortable temperature.A nurse is planning a teaching session for a client. Place the steps of the teaching process in the correct order. A. Planning B. Analysis C. Evaluation D. Assessment E. ImplementationD. Assessment B. Analysis A. Planning E. Implementation C. EvaluationA nurse is teaching a client who has a new prescription for antihypertensive medication. The nurse should identify that antihypertensive medications are used for which of the following types of prevention? a. Secondary b. Tertiary c. Primary d. QuaternarybA home health nurse is visiting a client who lives in an older home and is concerned about their child's exposure to lead paint in the house. The nurse should identify which of the following is a potential health risk from exposure to lead paint? a. Strabismus b. Dental caries c. Accelerated growth and development d. Learning disabilitiesdA nurse is teaching a newly licensed nurse about health literacy. Which of the following information should the nurse include? a. The client's signature on the discharge instructions ensures they understood the instructions. b. Clients who can read and write demonstrate health literacy. c. A client's comprehension of education can be affected by low health literacy. d. Health literacy affects only a small portion of clients who are cared for within the health care system.cA nurse teaches clients about the International Self-Care Foundation's seven pillars of self-care. Which of the following client statements indicates an understanding of the teaching? a. "I will perform moderate exercise several times each week." b. "I will wash my hands for 10 seconds before I eat." c. "I will increase my dietary intake of simple sugars." d. "I will limit my sun exposure to 1 hour in the middle of the day."aA nurse is teaching a group of guardians about primary prevention techniques. Which of the following topics should the nurse include as an example of primary prevention? a. Emphasizing the importance of well-child visits for the child b. Encouraging children who have asthma to participate in extracurricular activities c. Taking measures to decrease the risk of childhood injuries within the home d. Promoting a healthy lifestyle for children who are overweightcA nurse is discussing the Healthy People initiative with a newly licensed nurse. Which of the following information should nurse include? a. The program focuses on decreasing the occurrence of cancer in people. b. The program focuses upon issues related to global health. c. The program focuses on providing goals and data for improved public health. d. The program focuses on reducing the viruses acquired by people.cA nurse is speaking to a client who smokes tobacco and has a child living in the home. The nurse should identify that the child's exposure to second-hand smoke is an example of the following risk factors? a. Cultural b. Societal c. Heredity d. EnvironmentaldA nurse is preparing to administer an influenza vaccine to a client. The client states that they understand being immunized will help protect them against the influenza virus. Which of the following concepts is the nurse demonstrating by administering the vaccine? a. Health promotion b. Disease prevention c. Health outcomes d. WellnessbA nurse is teaching a client about modifiable risk factors to their health. Which of the following should the nurse include as an example of a modifiable risk factor? a. Tobacco use b. Age c. Family history d. RaceaA nurse teaches clients about the benefits of a healthy diet and regular exercise to achieve weight loss. Which of the following topics is the nurse teaching to the client? a. Health promotion b. Disease prevention c. Nonmodifiable risk factors d. Tertiary preventionaA nurse is caring for a client who reports an improved diet, exercising 30 min a day for 5 days a week, and an overall sense of improved health. The nurse should identify that the client is describing a positive state of health known as which of the following? a. Health promotion b. Disease prevention c. Health outcomes d. WellnessdA nurse at a clinic is providing free blood pressure screenings for clients. Which of the following levels of health prevention is the nurse demonstrating? a. Tertiary prevention b. Secondary prevention c. Primary prevention d. Quaternary carebA nurse at a hospital is interviewing a newly admitted client. The client tells the nurse they would like to adhere to their cultural beliefs during their hospitalization. Which of the following actions should the nurse take to provide the client with culturally competent care? (Select all that apply.) a. Listen to the client's request with respect and compassion. b. Let the client know that their cultural beliefs will be checked on after the assigned nursing break. c. Reassure the client that they can practice their cultural beliefs if safe to self and others. d. Explain to the client that this is not possible in a public space. e. Provide resources to meet the client's cultural needs.a, c, eA nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? A) Malaise B) Anorexia C) Headache D) DiarrheaD) DiarrheaA nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? A) A client who has peripheral vascular disease and reports numbness in the toes B) client who has depression & is easily distracted C) A client who has Alzheimer's disease and is unable to complete ADLS D) A client who had abdominal surgery 10 days ago and reports feeling his incision popD) A client who had abdominal surgery 10 days ago and reports feeling his incision popA nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? A) establishing a sense of achievement B) contributing to society C) creating meaningful social relationships D) enhancing self- confidenceC) creating meaningful social relationshipsA nurse is preparing to administer oral medication to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? A) Administer medications w/ meals when possible B) Ensure client understanding of medication's effects C) Determine the client's ability to self-administer meds D) have the client position the head w/ chin down while swallowingD) have the client position the head w/ chin down while swallowingA nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider? A) Lithium carbonate 0.8 mmol/L B) Digoxin 3.0 ng/mL C) Peak serum gentamicin 6 mcg/mL D) Magnesium sulfate 4 mEq/LB) Digoxin 3.0 ng/mLA nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? A) Ensure all 4 side rails are up. B) Administer a prescribed sedative. C) Place the client in soft wrist restraints D) Move the client to a room near the nurses' stationD) Move the client to a room near the nurses' stationA nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? A) Place the infant in a supine position when sleeping B) place the infant on a firm mattress when sleeping C) avoid covering the infant with loose bedding while sleeping D) avoid leaving stuffed animals in the crib with the sleeping infantA) Place the infant in a supine position when sleepingA nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? A) Obtain an ECG. B) Administer oral potassium C) Encourage potassium-rich foods D) Monitor I & OA) Obtain an ECG.A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? A) Place O2 at 2 L per nasal canula on the client B) Place the client in the orthopneic position C) Perform chest percussion D) perform nasotracheal suctionB) Place the client in the orthopneic positionA nurse is collecting data on four clients. Which of the following findings is the most urgent? A) bladder distension and urgency B) pedal edema C) warmth and pain in the calf D) hypoactive bowel soundsC) warmth and pain in the calfA nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? A) Initiate oxygen therapy B) encourage an increase in oral fluids C) provide room humidification D) Assist client to cough effectivelyD) Assist client to cough effectivelyA nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? A) Provide assistance w/ ambulation when indicated B) determine the mobility status of each patient C) Maintain the side rails of each be in the raised position D) Plan a fall prevention program for clients at riskB) determine the mobility status of each patientA nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention? A) Cholesterol 220 mg/dL B) Platelets 95,000 mm^3 C) BUN 20 mg/dL D) Potassium 3.5 mEq/LB) Platelets 95,000 mm^3A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? A) Check on the client B) unlock the crash cart C) begin cardiopulmonary resuscitation D) announce a codeA) Check on the clientA nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action? A) providing pain control B) preventing hemorrhage C) maintaining a patent airway D) ensuring adequate fluid intakeC) maintaining a patent airwayA newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster? A) immediate B) delayed C) minimal D) expectantA) immediateA nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? A) a client who is has a history of HF B) a client who has type 1 DM C) a client who is reporting pain associated w/ osteoarthritis of the knees D) a client who is having a nosebleed associated w/ hypertensionD) a client who is having a nosebleed associated w/ hypertensionA nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit? A) obtain an arterial pH level B) check the HR and BP C) insert an indwelling catheter D) collect a serum BUN and creatinineB) check the HR and BPA nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? A) Administer an anticoagulant B) Check the leg for warmth and Edema C) Apply elastic stockings D) Promote bed rest & extremity elevationB) Check the leg for warmth and EdemaA nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? A) homelessness B) lack of family support C) Hypoxic D) under nourishedC) HypoxicA nurse truthfully answers a client's questions about their laboratory results. The nurse is demonstrating which of the following ethical principles? a. justice b. nonmaleficence c. fidelity d. veracityd. veracityA nurse in an emergency department overhears a provider say they will not accept any more clients who do not have health insurance. Which of the following is the provider violating? a. The Emergency Medical Treatment and Labor Act (EMTALA) b. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) c. Tort law d. Good Samaritan lawsa. The Emergency Medical Treatment and Labor Act (EMTALA)A nurse is caring for a client who asks why they chose the nursing profession. The nurse states that it was because they wanted to help others. The nurse is referring to which of the following professional values? a. Integrity b. Human dignity c. Altruism d. Social justicec. AltruismA nurse is teaching a newly licensed nurse about professional values. The nurse should include that which of the following is an example of autonomy? a. A nurse provides the same quality care for every client. b. A nurse maintains client confidentiality. c. A nurse admits they forgot to change a client's dressing. d. A nurse respects a client's wish to discontinue a treatment.d. A nurse respects a client's wish to discontinue a treatment.A nurse is providing privacy for a client who has incontinence. The nurse is demonstrating which of the following professional values? a. Human dignity b. Altruism c. Social justice d. Autonomya. Human dignityA nurse stops at the side of the road to provide care to a person involved in a motor-vehicle crash. Which of the following protects the nurse from liability when administering care at the scene of an accident? a. Whistleblower protection b. Good Samaritan laws c. Torts d. Emergency Medical Treatment and Labor Act (EMTALA)b. Good Samaritan lawsA nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that which of the following situations is an example of fidelity? a. A nurse involves a client in making decisions about their care. b. A nurse implements fall precautions for a client who is at risk for falling. c. A nurse tells the truth about forgetting to perform a procedure for a client. d. A nurse keeps a promise to a client not to tell their family about their diagnosis.d. A nurse keeps a promise to a client not to tell their family about their diagnosis.A nurse notifies their supervisor that they accidentally administered the wrong medication to a client. The nurse is demonstrating which of the following professional values? a. Integrity b. Human dignity c. Altruism d. Social justicea. IntegrityA nurse is caring for a client who is alone and has just received a serious diagnosis. The client asks the nurse if they can pray together, and the nurse agrees. The nurse is demonstrating which of the following ethical principles? a. Autonomy b. Beneficence c. Nonmaleficence d. Justiceb. BeneficenceA nurse at the end of their shift realizes they forgot to give a client their scheduled vitamins. The nurse decides to document that the vitamins were administered. Which of the following describes the nurse's action? a. HIPAA violation b. Falsification of records c. Assault d. Defamationb. Falsification of recordsA nurse is preparing to administer a PRN pain medication to a client but withholds the medication because the client is sleeping. Which of the following actions should the nurse take to provide the expected standard of care? a. Document that the medication was not administered. b. Document that the client is not experiencing pain. c. Contact the provider to change the PRN prescription. d. Fill out an incident report about the situation.a. Document that the medication was not administered.A nurse suspects their coworker might be under the influence of a chemical substance. Which of the following actions should the nurse take? a. Counsel the coworker about substance use. b. Report the coworker to the ethics committee at the facility. c. Ask the coworker how long they have been using substances. d. Tell the charge nurse that the coworker might be impaired.d. Tell the charge nurse that the coworker might be impaired.A nurse who has been working 12-hr shifts on a busy unit is experiencing nurse fatigue. Which of the following effects can result from nurse fatigue? a. Increase in communication skills b. Increase in effective clinical judgment c. Increase in medication errors d. Increase in productivityc. Increase in medication errorsA nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that doctor said." Which of the following actions should the nurse take? a. Explain the procedure in detail to the client. b. Ask the provider to discuss the procedure with the client. c. Encourage the client to reread the consent form before signing. d. Tell the client that the surgeon will explain it to them in the operating room.b. Ask the provider to discuss the procedure with the client.A nurse is teaching a group of newly licensed nurses about professional values. Which of the following statements by a newly licensed nurse demonstrates an understanding of social justice? a. "Health care should be a right for everyone." b. "All clients should have a private room in a health care facility." c. "I plan to volunteer at the local homeless shelter on my days off." d. "I will respect a client's right to refuse a procedure."a. "Health care should be a right for everyone."A nurse in an emergency department is caring for four clients. Which of the following clients requires mandatory reporting? a. An adolescent client who has a fractured tibia following a football game b. A young adult client who is positive for tuberculosis c. An older adult client who has dementia, a history of falls, and bruising on their knees d. A preschooler who has frequent enuresisb. A young adult client who is positive for tuberculosisA nurse is teaching a client about advance directives. Which of the following client statements indicates an understanding of the teaching? a. "I need to choose a family member as my health care surrogate." b. "Once I sign my advance directives, I cannot change my decisions." c. "My health care surrogate will make health care decisions for me if I am unable." d. "I need to have an attorney present to complete my advance directives."c. "My health care surrogate will make health care decisions for me if I am unable."A nurse is providing equal care to a group of clients who have varying economic statuses. Which of the following ethical principles is the nurse demonstrating? a. Fidelity b. Autonomy c. Justice d. Veracityc. JusticeA nurse is reviewing standards of care with a group of newly hired nurses. The nurse should include which of the following incidents as an example of a breach of standards of care? a. A nurse did not read back a verbal medication prescription to a provider. b. A nurse did not return to a client's room with a promised blanket. c. A nurse documents client care as soon as it is completed. d. A nurse forgot to call a client's family after performing a procedure.a. A nurse did not read back a verbal medication prescription to a provider.A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that a client who has chosen to sign a blood product refusal form is an example of which of the following ethical principles? a. Veracity b. Beneficence c. Autonomy d. Fidelityc. Autonomy