Which intervention is compatible with the goals for end of life care?

Permitting the client with diabetes melitus to have a serving of ice cream

The nurse is having trouble reading a prescribe dose on a written order. What should the nurse do?

Call the health care provider to clarify the order

A patient with diabetes mellitus has orders for foot care. Which of the following is the rationale for the order

There is increased neuropathy with this pathology that places them at risk

Which one of the following actions is an example of an unintentional tort?

Leaving the side rails down and the client falls and is injured

Which of the following is an example of subjective data?

The client stating they feel "Hot"

Which of the following as an appropriate technique for nasotracheal suctioning?

Applying intermittent suction for 10 seconds during catheter removal

When should abnormal symptoms in a dying client be treated?

When they affect the client's rest or comfort

It has been determined that all of the clients are at risk for falling.Which one requires priority when ambulating?

A 45 year old post-op client up for the first time since knee surgery

As a community health nurse assisting the client and family with nutritional needs the nurse should first:

Ask the client and family what they think they should eat

The nurse begins the assessment for a client that has come to the ED for chest pain by asking the client about:

The onset, severity, and duration of the chest pain

Which clinical manifestation alerts you to the fact that the terminally ill client is approaching death?

The client's extremities are cold and mottled

When assessing members of a vulnerable population, the nurse should realize the primary need is to:

Create a comfortable, nonthreatening environment

Which of the following statements shows the greatest understanding of wound staging?

"This wound can't be staged until it's debrided."

What standard of care applies to the student nurse's conduct when providing care normally provided by a RN?

The same standard of care as an RN

Which one of the following individuals may legally give informed consent?

A 16 year-old for her newborn child

Which task should the critical care nurse delegate to the UAP?

Take the client's urine specimen to the laboratory.

To facilitate change within a community, the nurse working as an effective change agent should:

Work with clients to select alternative health care sites and treatments

Which of the following nursing situations best reflects accountability?

The nurse files an incident report regarding a medication error

The spouse of a dying client is concerned because the client does not want to eat. What is your best response?

"Let him know that food is here if he wants it, but don't insist he eats"

The nurse is interviewing a client using open-ended technique. Which reflects this type of questioning.

"What do you think has been causing your your current depression?"

A patient is scheduled to have ambulatory surgery. Which information is of most concern to the nurse?

The patient is planning to drive home after surgery

A nurse notices a blanchable area 2cm in diameter on the clients left buttock. The nurse's initial intervention is to:

Position the client on her right side

To promote respiratory function in the immobilized client, the nurse should

Encourage deep breathing and coughing every hour

Which of the following is an appropriate nursing intervention for a client with a NG tube in place

Mark the tube where it exits the nose

Th nurse hung the wrong IV antibiotic for the postoperative client. Which intervention should the nurse implement first?

Assess the client for any adverse reactions

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Answers

1
Which intervention is compatible with the goals for end of life care?
Performing passive range of motion excercises to prevent contractures
preventing the client with COPD from smoking
Permitting the client with diabetes melitus to have a serving of ice cream
Administering a flu shot
2
The nurse is having trouble reading a prescribe dose on a written order. What should the nurse do?
Ask another RN to confirm the order
Request the pharmacist to interpret the order
Call the health care provider to clarify the order
Consult a current drug book to determine the normal dosage range
3
This program recognizes health care organizations that achieve excellence in nursing practice
Magnet recognition progam
Nightingale Excellence Award
Recognition of service excellence (R.O.S.E)
The DAISY award
4
A advanced beginner is a nurse who hase some experience and is able to identify meaningful aspects or principles of care
False
True
5
A patient with diabetes mellitus has orders for foot care. Which of the following is the rationale for the order
The aging process causes increased skin breakdown
The client probably has a history of poor hygienic care
There is increased neuropathy with this pathology that places them at risk
The lower extremities are difficult to see and therefore hard to maintain
6
This type of care includes diagnosis and treatment of common illnesses
Primary prevention
Primary Care
Tertiary Care
Secondary Care
7
Droplet precautions will be instituted for the client admitted to the infectious disease unit with:
Herpes simplex
Streptococcal pharyngitis
Pertussis
Measles
8
A doctor order 90 mg of atenolol to be given,the medicine is available in 15 mg tablets. How many tablets?
4
5
6
3
9
A client with Crohn's eats a well balanced diet that keeps his GI symptoms supressed. What type of prevention is this?
Tertiary Prevention
Health Promotion
Primary Prevention
Secondary prevention
10
Which one of the following actions is an example of an unintentional tort?
Talking about a client's history of Sexually transmitted diseases
Restraining a client who refuses care
Leaving the side rails down and the client falls and is injured
Taking photos of a client's surgical wounds
11
__________ is the most reported infectious disease in the United States
HPV
Chlamydia
Syphilis
Gonorrhea
12
A client with acive tuberculosis is admitted to the medical center. What type of precautions is recommended for this PT?
Droplet precautions
Contact precautions
Airborne precautions
Reverse isolation
13
Which of the following is an example of subjective data?
Blood pressure of 160/80 mm Hg
Pulse rate of 88 Bpm
The client stating they feel "Hot"
Temperature of 38.2 degrees celcius
14
Which of the following as an appropriate technique for nasotracheal suctioning?
Placing the client in a supine position
Suctioning the oropharyngeal area first, then the nasotracheal area
Prepare for a clean or nonsterile technique
Applying intermittent suction for 10 seconds during catheter removal
15
When should abnormal symptoms in a dying client be treated?
When they affect the client's rest or comfort
When they do not interfere with religious beliefs
When they disturb the family
When they are serious and may lead to death
16
It has been determined that all of the clients are at risk for falling.Which one requires priority when ambulating?
A 16 year old with a sprained ankle being discharged from the ED
A 54 year old who has taken the initial dose of an antihypertensive drug
An 81 year old who is asthmatic and had a hip replaced 18 months ago
A 45 year old post-op client up for the first time since knee surgery
17
As a community health nurse assisting the client and family with nutritional needs the nurse should first:
Identify for the client the best foods to buy
Provide information on stores with the most reasonable pricing
Purchase foods at the lowest cost for the client
Ask the client and family what they think they should eat
18
The nurse begins the assessment for a client that has come to the ED for chest pain by asking the client about:
The onset, severity, and duration of the chest pain
A family history of heart problems
Medications currently being taken at home
Questions or concerns about hospitalization
19
The nurse decides to administer tylenol instead of demerol. Which step of the nursing process does this address?
Nursing diagnosis
Implementation
Assessment
Planning
20
Which of the following lab value is monitored during wound healing
Prealbumin
potassium
Biotin
magnesium
21
A nurse is caring for a patient who practices the islamic faith. When planning out dinner the nurse knows not to include
Beef
Pork
Fish
Chicken
22
Which clinical manifestation alerts you to the fact that the terminally ill client is approaching death?
The client's pain is increasing
The client's extremities are cold and mottled
The client calls one son by the other son's name
The client has asked to see a minister
23
When assessing members of a vulnerable population, the nurse should realize the primary need is to:
Create a comfortable, nonthreatening environment
Organize in your mind exactly what you need to ask
Provide cultually competent assessment
Be alert for indications of mental and physical abuse
24
Which of the following statements shows the greatest understanding of wound staging?
"This wound can't be staged until it's debrided."
"The health care provider will need to stage the ulcer."
"A wound that contains slough is difficult to stage."
"An ulcer must involve broken skin in order to be staged."
25
Tertiary Care is a specialized consultative care, usually provided on referral from secondary medical personnel
True
False
26
What standard of care applies to the student nurse's conduct when providing care normally provided by a RN?
A standard similar to but not the same as the staff nurse
A standard of care of an unlicensed person
No special standard because her faculty member is responsible for her
The same standard of care as an RN
27
Which one of the following individuals may legally give informed consent?
A 16 year-old for her newborn child
A sedated 42- year old preoperative client
A 56-year-old who does not understand the proposed treatment plan
The friend of an 84- year old married client
28
Which task should the critical care nurse delegate to the UAP?
Check the pulse oximeter reading for the client on a ventilator.
Obtain the vital signs for the client in an addisonian crisis
Take the client's urine specimen to the laboratory.
Assist the HCP with performing a paracentesis at the bedside
29
The nurse is working on a pulmonary unit. The nurse is alert to one of the early signs of hypoxia which is:
A decreased blood pressure
A decreased respiratory rate
Restlessness
Cyanosis
30
To facilitate change within a community, the nurse working as an effective change agent should:
Formulate decisions for clients regarding their health care options
Provide instructions in the way the community should address health issues
Work with clients to select alternative health care sites and treatments
Inform community members how to effectively manage their health needs
31
TED hose are ordered fo a client on bed rest following surgery.The nurse tells the client the purpose for the TEDS is to
Keep the skin warm and dry
Prevent abnormal joint flexion
Apply external pressure
Prevent bleeding
32
Which of the following nursing situations best reflects accountability?
The nurse takes the oncology nursing certification examination
The nurse tells the client, " I don't know but I will find out for you."
The nurse assesses the client for the possible cause of his pain
The nurse files an incident report regarding a medication error
33
In preventing and controlling the transmission of infections, the single most important technique is:
Hand hygiene
Sterilization of equipment
The use of isolation precautions
The use of disposable gloves
34
The nurse is caring for a patient who has difficulty understanding written and spoken word? This is __________ Aphasia
Wernicke's
Broca's
Receptive
Expressive
35
The spouse of a dying client is concerned because the client does not want to eat. What is your best response?
"Let him know that food is here if he wants it, but don't insist he eats"
"Force him to eat even if he doesn't feel hungry, or he will die sooner."
"He is getting all the nutrients he needs through his IV."
"A feeding tube can be placed in the nose to provide important nutrients."
36
A client newly diagnosed with cancer states the lab must have made a mistake. This client is most likely experiencing?
Depression
Bargaining
Anger
Denial
37
A client refuses a medication but the nurse gives it anyway. This is an example of which kind of intentional tort?
Battery
Invasion of privacy
Assault
Malpractice
38
An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as:
Harsh crackles
Diminished breath sounds
Bronchovesicular whooshing
Wheezing on inspiration
39
This type of care includes Adult screenings for blood pressure, cholesterol, tobacco use, and cancer
Preventive Care
Primary Care
Secondary Care
Tertiary Care
40
The nurse is interviewing a client using open-ended technique. Which reflects this type of questioning.
"What do you think has been causing your your current depression?"
"Is your pain worse or better than it was an hour ago?"
"Do you believe that your nausea is from the new antibiotic?"
" What have you done to alleviate the side effects from your medication?"
41
A nurse is working on a ICU floor and notices a fire. The nurses first reponse is to do:
Pull the fire alarm
Rescue the patients
Extinguish the fire
Confine the fire
42
PH: 7.28 (Normal 7.35-7.45) CO2: 50 (Normal 35-45mmHg) HCO3 : 24 (Normal 22-26 mEq/L)
Respiratory alkalosis
Metabolic alkalosis
Metabolic acidosis
Respiratory acidosis
43
A patient is scheduled to have ambulatory surgery. Which information is of most concern to the nurse?
The patient is planning to drive home after surgery
The patient has eaten at 9 pm the night before
The ppatient has not had outpatient surgery before
The patient's insurance does not cover outpatient surgery
44
A nurse notices a blanchable area 2cm in diameter on the clients left buttock. The nurse's initial intervention is to:
Finish providing fresh, dry linen to the client's care plan
Position the client on her right side
measure the area in order to describe it in the nurses' notes
Include a 2-hour turning schedule in the client's care plan
45
What age should a client start doing self testicular exams?
13
15
14
12
46
Which of the following clients is most at risk for developing a pressure ulcer
33-year old comatose client
3-year old in buck's traction
38-week old infant in an oxygen hood
76-year old client who has a mild stroke
47
To promote respiratory function in the immobilized client, the nurse should
Use oxygen and nebulizer treatments regularly
Suction the client's secretions every hour
Encourage deep breathing and coughing every hour
Change the client's position every 4 to 8 hours
48
A __________ is a predictable and often unavoidable adverse effect produced at a usual therapeutic dose
Allergic reaction
Side effect
Toxic effect
Idiosyncratic reaction
49
PH: 7.23 (Normal 7.35-7.45) CO2: 50 (Normal 35-45mmHg) HCO3 : 30 (Normal 22-26 mEq/L)
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis
50
Which of the following is an appropriate nursing intervention for a client with a NG tube in place
Mark the tube where it exits the nose
Change the tubing daily
Tape the tube up and around the ear on the side of insertion
Secure the tubing to the bed by the client's head
51
Th nurse hung the wrong IV antibiotic for the postoperative client. Which intervention should the nurse implement first?
Complete the incident or adverse occurrence report
Notrify the client's healthcare provider
Assess the client for any adverse reactions
Administer the correct intravenous antibiotic medication
52
The client is admitted to the medical center with right sided heart failure. In the assessment the nurse expects to find
Peripheral edema
Confusion
Dyspnea
Dizziness
53
The nurse is giving a IM injection of Vitamin B12. The nurse knows that this is one of the many sites an IM can be given
Ventrogluteal
Vastus lateralis
Deltoid
Sternocleidomastoid
54
When should self breast exams occur?
8 Days after menstrual cycle
7 days after menstrual cycle
9 days after menstrual cycle
6 days after menstrual cycle
55
A client is getting up for the first time after a period of bed rest. The nurse should first:
Assess respiratory function
Assist the client with sitting at the edge of the bed
Obtain a baseline blood pressure
Ask the client if he or she feels light headed
56
A nurse is assessing an elderly client in a nursing home facility. An expected finding for this client is:
Increased hearing acuity for higher tones
Increased tactile responsiveness
increased thoracic expansion during ventilation
Increased sensitivity to visual glare
57
The nurse is caring for a client with right sided paralysis. Which of the following factors would result in a ulcer?
Skin secretion
Immobility
Reduced hydration
Poor nutrition
58
When discussing a need for excercise the client states "Ew no." The nurse knows the client is in which stage.
Maintenance stage
Contemplation
Precontimplation
Preperation
59
_____________ the focus is on the health and development of an individual member existing within a family environment.
Family as a patient
Family as a system
Family as a context
Family as a whole
60
The client is to recieve kayexalate enema. The nurse recognizes that this used to:
Reduce bacteria in the colon before diagnostic testing
Provide direct antidiarrheal medication to the intestine
Prevent further constipation
Remove excess potassium from the system
61
What is the minimum ammount of urine output that the nurse should see per hour
40 mL
50 mL
20 mL
30 mL
62
Concerning the legalities of death and dying issues, which of the following is true?
Organ donation must be attempted if it will save the recipient's life
Passive euthanasia is illegal in all states
Assisted suicide is a constitutional right
Feedings may be refused by competent individuals who are unable to self eat
63
The student is looking at types of practice settings. In looking at community health nursing the student knows that it:
Requires graduate level education preperation
Focuses on the incidence of disease
Includes direct care and services to subpopulations
Is the same as public health nursing
64
An 8 month old is hospitilized with severe diarrhea. The nurse knows what major problem is linked with this issue:
Electrolyte and fluid loss
Iritation of the perineal and rectal area
Presence of excessive flatus
Pain in the abdominal area
65
PH: 7.30 (Normal 7.35-7.45) CO2: 40 (Normal 35-45mmHg) HCO3 : 18 (Normal 22-26 mEq/L)
Metabolic alkalosis
Metabolic acidosis
Respiratory acidosis
Respiratory alkalosis
66
Which of the following represents a major philosophy of the hospice concept?
Ensuring that a terminally ill client is never alone
Improving the quality of life for a client with a terminal illness
Assisting the family of a terminally ill client to grieve more efficiently
Removing the stigma of death
67
Which of the following is one of the five rights of med admin
Right drug
Right time
Right route
Right person
68
True or false the nurse gives the risks and benefits of the surgery in the preop stage
True
False
69
After a with a client, the nurse documents the objective and subjective info. Which of the following is objective?
Pain in the left leg
Fear of impending surgery
Discomfort upon breathing
Elevated Blood pressure
70
A nurse incorrectly interprets a doctors med order and gives 10mg more then what was ordered. Who is responsible?
Pharmacy
The doctor
My buddy Jim
The nurse
71
In assessing the structure of the community in order to identify needs of the population the nurse will focus on:
collecting demographic data on age distribution
Interviewing clients to determine the cultural composition of the subgroups
Observing locations where services, such as water sanitation, are provided
visiting neighborhood schools to review health records
72
This type of care is provided by a specialist or agency on referral by a primary health care provider.
Primary Care
Tertiary Care
Paliative Care
Secondary Care
73
This form of touch is being used when a nurse catches a patient when they are falling
Physical
Protective
Emotional
Caring
74
The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to:
Palpate the temperature of the feet
Observe for a loss of hair and skin turgor in the lower legs
Attempt to elicit Homans' sign
Measure the calf and thigh circumferences
75
The nurse is assisting the adult female client with perineal care. What position should the client be placed in?
Supine
Dorsal recumbent
Prone
Side-lying
76
To reduce pressure points that may lead to pressure ulcers, the nurse should:
Position the client directly on the trochanter when side-lying
Use a donut device for the client when sitting up
Elevate the head of the bed as little as possible
massage over the bony prominences
77
When teaching a group about the HPV vaccine the nurse knows that her target audience is:
11 to 26 year olds
44 to 56 year olds
32 to 41 year olds
30 to 38 year olds
78
The primary source of info when completing an assessment of an alert and oriented client is
Physician
Experienced unit nurse
Client
Family Member
79
When a nurse signs as a witness on an informed consent form, she is indicating that the client:
Fully understands the procedure
Has authorized the physician to continue with the treatment
Agrees with the procedure to be done
Has voluntarily signed the consent form
80
Which of the following is used to monotor heparin therapy?
Ptt
prealbumin
albumin
aPtt
81
Which of the activities represents primary level intervention regarding STD in a homeless shelter?
Gynecological referrals for female residence
Sex education for teenage residents
HIV screening for all residents
Treatments for residents diagnosed with AIDS
82
The uniqueness of each family is referred to as family
Diversity
Resiliency
Durability
Forms
83
While undergoing a soapsuds enema, the client complains of abdominal cramping, The nurse should:
Lower the height of the enma container
Clamp the tubing
Immediately stop the infusion
Advance the enema 2 to 3 inches
84
A nurse who has no previous level of experience and follows a specific set of rules is in which level of benner's model
Novice
Starter
Beginner
Learner
85
Which of the following clients is at greatest risk for acquiring a health care associated infections
A trauma victim taken directly from the ED to surgery and then to PACU
A pregnant client with sinusitis and otitis media prescibed antibiotics
A client with type 1 diabetes who has been experiencing hypoglycemia
A 32 year old hospitalized for 2 days for migraine headaches
86
A nurse hears high pitched popping sounds when auscultating the lungs. The nurse is more then likely hearing which sound
Fine Crackles
Stridor
Polyphonic wheezing
Coarse crackles
87
The client manager is discussing osteoporosis with the staff. Which of the following is a secondary intervention?
Encouraging the client to walk 30 minutes daily on a hard surface
Perform a spinal screening examination on all female clients
Obtain a bone density evaluation test on a female client older than 50
Discuss risk factors for developing osteoporosis
88
A client who's house is torn apart by a flood experiences what type of crisis
Situational
perceived
Adventitious
Devlopmental
89
Which theorist described the basic human needs?
Peplau
Maslow
Orem
Leninger
90
Which concept associated with sleep must the nurse understand to best plan nursing care?
Total time in bed gradually decreases as one ages
Alcohol intake interferes with one's ability to fall asleep
Sleep needs remain consistent throughout the life span
Bedtime routines are associated with an expectation of sleep
91
How often should restraints be taken off?
Every 4 hours
Every 2 hours
Every 3 hours
Every 5 hours
92
Which of the following statements by the home health nurse best reflects client advocacy in response to expense concerns
"Have you considered the possibility of a renal transplant?"
"Let's call the dialysis center and explore options to lower the cost"
"You must feel awful about this situation, but this is the best option."
"This peritoneal dialysis is less expensive then hemodialysis."
93
Which of the following has the greatest possibility of contributing to a nosocomail infection and requires correction?
Placing a Foley catheter bag on the bed when transferring a client
Washing hands before applying a dressing
Using alcohol to cleanse the skin before starting a IV line
Taping a plastic bag to the bed rail for tissue disposal
94
_____________ the family's needs, processes, and relationships are the primary focus of nursing care
Family as a system
Family as a whole
Family as a patient
Family as a context
95
Patient's in the Action stage are actively engaged in strategies to change behavior, which lasts up to 4 months
True
False
96
The nurse instructs the client that before the fecal occult blood test she may eat
Whole wheat bread
Veal
Salmon
A lean T-bone steak
97
Which of the following sensory changes are normal with aging?
Heightened sense of smell
Impaired night vision
Increase in taste discrimination
Difficulty hearing low pitch
98
Which one of the following clients from a vulnerable population currently appears to be at the greatest risk?
An older adult taking medications for hypertension
A schizophrenic client in outpatient therapy
A physically abused client in a shelter
A substance abuser who shares drug paraphernalia
99
What is the correct order for putting on PPE?
Put on gown, apply mask and eyewear, wash hands and then apply gloves
Apply mask and eyewear, put on gown, wash hands, and apply gloves
Wash hands, Put on gown, apply mask and eyewear, and apply gloves
Wash hands, apply mask and eyewear, put on gown, and apply gloves
100
The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the UAP?
Instruct the UAP to apply SCD to the client on strict bed rest.
Request the UAP to prepare the client for a wound debridement
Ask the UAP to assist the radiology tech to perform a STAT chest X-ray
Tell the UAP to obtain the I&Os for all the clients on the unit

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