Content Mastery Series Review 2024 test, Exams of Nursing

Download Content Mastery Series Review 2024 test and more Exams Nursing in PDF only on Docsity! Content Mastery Series Review 2024 test  A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? - Correct answer Home health care  Rehabilitation facilities  Skilled nursing facilities  A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? - Correct answer Medicare  Medicaid  A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? - Correct answer Collaborating with providers to perform obesity screenings during routine office visits  A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following should the nurse identify as the responsibility of state licensing boards? - Correct answer Ensuring that health care providers comply with regulations  A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as TERTIARY care? - Correct answer Intensive Care Unit  Oncology treatment center  Burn Center  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? - Correct answer A client who has terminal cancer requests hospice care in her home  A client asks about community resources available for older adults  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? - Correct answer Occupational Therapy  A client who is postoperative following knee arthroplasty is concerned 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? - Correct answer Provider  Pharmacist  Registered Nurse  A client who has had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? - Correct answer 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 client activities should  she include? (Select all that apply.) o Bathing o Ambulating o Toileting o Determining pain level o Measuring vital signs - Correct answer Bathing  Ambulating  Toileting  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  Document objective data, leaving out opinions  A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? - Correct answer Medication Error  Needlesticks  Omission of prescription  A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? - Correct answer Repeat the details of the prescription back to the provider  Have another nurse listen to the telephone prescription  obtain the provider's signature on the prescription within 24 hr.  A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel? - Correct answer Reapplying a condom catheter for a client who has urinary incontinence  A nurse manager of a med-surge unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign to the client? - Correct answer RN  A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP?  Select all: o the roommate is up independently o The client ambulates with his slippers on over his antiembolic stockings o The client uses a front wheeled walker when ambulating o The client had pain meds 30 minutes ago o The client is allergic to codeine o the client ate 50 % of his breakfast this morning - Correct answer The client ambulates with his slippers on over his antiembolic stockings  the client uses a front wheeled walker when ambulating  the client had pain medication 30 min ago  An RN is making assignments for a  practical nurse (PN) at the beginning  of the shift. Which of the following  assignments should the PN question? o Assisting a client who is  24-hr postoperative to use  an incentive spirometer  B. Collecting a clean-catch  urine specimen from a client  who has a wound infection  C. Providing nasopharyngeal  suctioning for a client  who has pneumonia  D. Teaching a client who  has asthma to use a  metered-dose inhaler - Correct answer Teaching a client who  has asthma to use a  metered-dose inhaler  A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? - Correct answer Right supervision and evaluation  Right direction and communication  Right circumstances  By 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? - Correct answer Reassess the client to determine the reasons for inadequate pain relief  A newly licensed nurse is reporting to  the charge nurse about the care she  gave to a client. She states, "The client  said his leg pain was back, so I checked  his medical record, and he last received  his pain medication 6 hours ago. The  prescription reads every 4 hours PRN for  pain, so I decided he needs it. I asked  the unit nurse to observe me preparing  and administering it. I checked with  the client 40 minutes later, and he said  his pain is going away." The charge  nurse should inform the newly licensed  nurse that she left out which of the  following steps of the nursing process? o Assessment o Planning o Intervention o Evaluation - Correct answer Assessment  A 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? - Correct answer Respiratory rate is 22/min with even, unlabored respirations  Skin is pink, warm, and dry  The assistive personnel reports the client walked with a limp  A 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? - Correct answer Showing a client how to use progressive muscle relaxation  performing a daily bath after an evening meal  repositioning a client every 2 hours to reduce pressure ulcer risk  A 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 step of the nursing process? - Correct answer "I will determine the most important client problems that we should address"  A nurse is caring for a client who is 24 hr 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 that she will call the surgeon and asks. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? - Correct answer Basic (thinking is concrete and based on a set of rules)  A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? - Correct answer Responisibility  A nurse is caring for a client who is postoperative following abdominal surgery. The nurse suspects the client's pain management is inadequate. Which of the following data reinforce this suspicion. - Correct answer The client is nonadherent with coughing, deep breathing, and dangling  One gloved hand with the other gloved hand  A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? - Correct answer Wash the hands with soap and water for at LEAST 15 seconds  Use a clean paper towel to turn off hand faucets  A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? - Correct answer The nurse moistens a cotton ball with sterile NORMAL saline and places it on the sterile field  The procedure is delayed by 1 hr because the provider receives an emergency call  The nurse turns to speak to someone who enters through the door behind the nurse  A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? - Correct answer Planning and evaluating control and prevention strategies  Determining public health priorities  Ensuring proper medical treatment  monitoring for common-source outbreaks  A nurse is caring for a client who presents with linear clusters of FLUID- containing vesicles with some crusting. The nurse should identify the client has manifestations of which of the following conditions? - Correct answer Herpes zoster  A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? - Correct answer Illness  A nurse educator is reviewing with a newly hired nurse with the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? - Correct answer Fever  Malaise  Increase in pulse and respiratory rate  A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all. o Place the client in a room that has negative air pressure of at least 6 exchanges/hr o Wear a mask when providing care within 3 ft of the client o Place a surgical mask on the client if transportation to another dept is unavoidable o Use sterile gloves when handling soiled linens o Wear a gown when preforming care that may result in contamination from secretions - Correct answer Wear a mask when providing care within 3 ft of the client  Place a surgical mask on the client if transportation to another dept is unavoidable  Wear a gown when performing care that may result in contamination from secretions  A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? - Correct answer Make sure the call light is within reach  Provide the client with nonskid footwear  Complete a fall-risk assessment  A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? - Correct answer "I will go to the nurses' station for assistance"  YOU NEED TO STAY WITH PATIENT  A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? - Correct answer Move clients who are nearby  A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority - Correct answer Complete a fall-risk assessment  A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? - Correct answer An older adult who is postoperative following a below-the-knee amputation  A nurse is providing discharge instructions to a client who has a prescription for O2 use at home. Which of the following information should the nurse include about home O2 safety - Correct answer Nail polish should not be used near a client who is receiving oxygen  A "no smoking" sign should be placed on the front door  A fire extinguisher should be readily available in the home  A nurse educator is presenting a module on basic first aid for newly licensed home health health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? - Correct answer Hypotension  A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the following instructions? - Correct answer "Once my infant starts to push up, I will remove the mobile from over the crib."  A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? - Correct answer Carbon monoxide binds with hemoglobin in the body  A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? - Correct answer Immunocompromised individuals are at risk for complications from food poisoning  Clients who are at high risk should eat or drink only pasteurized dairy products  Handling raw and fresh food separately can prevent food poisoning  A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? - Correct answer Semi-Fowler's  A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? - Correct answer Determine the client's ability to help with the transfer proceed - Correct answer "For now, I should continue to have a mammogram each year."  A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? - Correct answer The client is able to demonstrate the appropriate technique  A nurse in a provider's office is collecting data from the mother of a 12 m/o infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the following domains? - Correct answer Affective  The client's ideas about toilet training has changed  A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to listen? - Correct answer "Can you tell me about how long the surgery will take?"  A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? - Correct answer Determine what the client already knows about stress incontinence  A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now, which of the following actions should the nurse take to evaluate the client's learning? - Correct answer Ask the client to explain how to select or prepare meals  A nurse is talking with the parents of a 6 m/o infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? - Correct answer Rolls from back to front  Bears weight on legs  Sits unsupported  A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? o "My baby loved to play with his crib gym, but I took it away from him." o "I just bought a soft mattress so my baby will sleep better." o "My baby really likes sleeping on the fluffy pillow we just got for him." o "I just bought a child-safety gate that folds like an accordion." - Correct answer A. "My baby loved to play with his crib gym, but I took it away from him."  A nurse is reviewing car seat safety with the parents of a 1 m/o infant. When reviewing care seat use, which of the following instructions should the nurse include? - Correct answer Position the car seat so that the infant is rear-facing  A nurse is assessing from a 2 week old newborn during a routine checkup. Which of the following findings should the nurse expect? - Correct answer Sleeps 14 to 16 hours a day  Hands remain in a closed position (usually until 2 m/o)  Current weight same as birth weight (loses it during first week and gains it back during second week)  The mother of a 7 m/o infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? - Correct answer Let's make a list of the foods he is eating so we can spot any problems  Did the changes begin after you started on particular food?  Has he been vomiting since he started these new foods?  A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? - Correct answer Store toxic agents in locked cabinets  Turn pot handles toward the back of the stove  Place safety gates across stairways  A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? - Correct answer Filling and emptying containers  Playing with blocks  Looking at books  A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? - Correct answer Establish consistent boundaries for the toddler  A mother tells the nurse that her 2 y/o has temper tantrums and says "no" every time the mother tries to help her get dressed. The nurse should recognize that the toddler is manifesting which of the following stages of development? - Correct answer Trying to increase her independence  A nurse is reviewing nutritional guidelines with the parents of a 2 y/o toddler. Which of the following parent statements should indicate an understanding of teaching - Correct answer "I'll give my son about 2 tablespoons of each food at mealtimes"  A nurse is talking with the parent of a 4 y/o child who states that his child is waking up with nightmares. Which of the following interventions should the nurse suggest? - Correct answer Have the child take an afternoon nap  A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? - Correct answer Assembling puzzles  Using musical toys  Playing with puppets  Coloring with crayons  A nurse is planning to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medications? - Correct answer Have the parents bring in a favorite toy from home  Engage the child in pretend play with a toy medical kit  A nurse is reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the parents of preschoolers. Which of the following vaccines should the nurse include in this discussion? - Correct answer Varicella  Polio  Seasonal influenza  A nurse is talking with a parent who is concerned about several issues with her preschooler. Which of the following issues should the nurse identify as the priority? - Correct answer "My son has temper tantrums every time we tell him to do something he does not want to do."  A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? - Correct answer Wear a helmet when skiing  Install a carbon monoxide detector  Secure firearms in a safe location  A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood? - Correct answer The client expresses concerns about the next generation  A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? - Correct answer Spend time focusing on improving job performance  Welcome opportunities to be creative and productive  Become involved with community issues  A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? - Correct answer Metabolism  Gastric secretions  Glomerular filtration  A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? - Correct answer Eye examination every 1 to 3 years  DXA screening for osteoporosis  Increase intake of carbohydrate in the diet  Screening for depressive disorders  A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? - Correct answer "It's been so stressful for me to think about having intimate relationships"  A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? - Correct answer "I keep forgetting which medications I have taken during the day."  A nurse is providing teaching for an older adult client who has lost 4.5kg (9.9lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? - Correct answer "Eat foods that are easy to eat, such as finger foods."  "invite family members to eat meals with you."  "Exercise every day to increase appetite."  A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? - Correct answer Pneumococcal immunization  Yearly eye examination  Periodic mental health screening  Annual fecal occult blood test  A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? - Correct answer Increase protein intake to increase muscle mass  Increase calcium intake to prevent osteoporosis  Limit sodium intake to prevent edema  Increase fiber intake to prevent constipation  A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? - Correct answer Decreased height  Nail thickening  Decreased bladder capacity  A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) o Address the client with the appropriate title and her last name. o Use a mix of open- and closed-ended questions. o Reduce environmental noise. o Have the client complete a printed history form. o Perform the general survey before the examination. - Correct answer Use a mix of open- and closed-ended questions  Reduce environmental noise  Perform the general survey BEFORE the examination  A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? - Correct answer Posture  Skin lesions  Speech  A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's ABDOMEN, which of the following skills of the physical examination process should she perform next? - Correct answer Auscultation*  Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next and before using those 2 techniques  A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? - Correct answer Plan to allow plenty of time for position changes  Make sure the client has any essential sensory aids in place  Tell the client to take her time answering questions  Invite the client to use the bathroom before beginning the examination  A nurse in a family practice clinic is  performing a physical examination  of an adult client. Which part  of her hands should she use  during palpation for optimal  assessment of skin temperature?  During a cardiovascular examination,  a nurse in a provider's office places  the diaphragm of the stethoscope  on the left midclavicular line at  the fifth intercostal space. Which  of the following heart sounds  is the nurse attempting to  auscultate? (Select all that apply.) o Ventricular gallop o Closure of the mitral valve o Closure of the pulmonic valve o Closure of the tricuspid valve o Murmur - Correct answer Closure of the mitral valve  Closure of the tricuspid valve  A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? - Correct answer Tympany  High-pitched clicks  A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? - Correct answer Capillary refill less than 2 seconds  Thick skin on the soles of the feet  Numerous light brown macules on the face (ex: freckles)  A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? - Correct answer Loss of adipose tissue  Dehydration  Diminished skin elasticity  A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? - Correct answer Skin color  Edema  Skin temperature  A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? - Correct answer Herpes simplex  Varicella  A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate action - Correct answer Cyanosis (indicative of hypoxia)  A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? - Correct answer Concave lumbar spine posteriorly  Muscles slightly larger on his dominant side  A nurse is assessing a client's neurosensory system. To evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items? - Correct answer A familiar object she places in his hand  A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the client's ability to perform which of the following activities? - Correct answer Fastening her bra behind her back  A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the client's balance? - Correct answer Romberg test  Heel-to-toe walk  A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? - Correct answer Some vision and hearing decline  Slower fine finger movement  Some short-term memory decline  A 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 about going home today?" Which clarifying technique is the nurse using to enhance the communication with the client? - Correct answer Reflecting  Which of the following actions should the nurse take when using the communication technique of active listening? - Correct answer Use an open posture  Establish and maintain eye contact  Respond positively when giving feedback  A 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? - Correct answer "Your daily routines will be different when you get home"  "Tell me about your support system you'll have after you leave the hospital"  "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."  Which of the following strategies should a nurse use to establish a helping relationship with a client? - Correct answer Encourage the client to communicate his thoughts and feelings  A 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? - Correct answer Sit at eye level with the child  A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? - Correct answer "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."  A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in the blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? - Correct answer Alarm reaction  A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situation role change based on physical limitations. The client is the primary wage earner in the family, which of the following describes the client's role problem? - Correct answer Role conflict self-care should the nurse communicate to the family? - Correct answer The client's sense of loss can be lessened through retaining control of certain areas of her life.  A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter's wedding." Based on Kübler-Ross' model, which stage of grief is the client experiencing? - Correct answer Bargaining  A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? - Correct answer "Would you like me to contact the chaplain to come speak with you?"  "You know, it's quite normal to feel anger toward your husband at this time"  "Tell me more about how you are feeling"  A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? - Correct answer Decreased muscle tone  A nurse is assisting a newly licensed nurse with the postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicates an understanding of the procedure? - Correct answer I will apply fresh linens and place a clean gown on the body  I will remove all equipment from the bedside  I will dim the lights in the room  A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? - Correct answer Turn the client's head to the side  A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? - Correct answer Inspect feet daily  Use moisturizing lotion on the feet  Wear cotton socks  A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care - Correct answer Schedule rest periods during morning care  A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? - Correct answer Face  A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? - Correct answer Brush the dentures with a toothbrush and denture cleaner  A nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? - Correct answer "Does your lack of sleep interfere with your ability to function during the day?"  "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?"  "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?"  "Tell me about any personal stress you are experiencing"  A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? - Correct answer Practice muscle relaxation techniques  Exercise each morning  Alter the sleep environment for comfort  Limit fluid intake at least 2 hr before bedtime  A nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? - Correct answer Allow the client to take a bath in the evening  A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? - Correct answer REM sleep provides cognitive restoration  It is difficult to awaken a person in REM sleep  Vivid dreams are common during REM sleep  A nurse is instructing a client who has a new diagnosis of NARCOLEPSY about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? - Correct answer I'll take a short nap whenever I feel a little sleepy.  A nurse is caring for a client who is at a high risk for aspiration. Which of the following actions should the nurse take? - Correct answer Instruct the client to tuck her chin when swallowing  *Tucking the chin allows food to pass down the esophagus more easily  A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? - Correct answer Carbohydrates  A nurse is caring for a client who requires a low-residue (low in fiber / easy to digest) diet. The nurse should expect to see which of the following foods on the client's meal tray? - Correct answer Vanilla custard  A nurse is caring for a client who weighs 80 kg and is 1.6 m tall. Calculate her BMI and determine if she is normal, overweight, or obese. - Correct answer (80kg)/(1.6m x 1.6m) = 31.25  OBESE (anything over 30 is obese)  A nurse in a senior center is counseling a group of older adults about her nutritional needs and considerations. Which of the following information should the nurse include? - Correct answer Older adults are more prone to dehydration than younger adults are  Older adults need the SAME amount of most vitamins and minerals young adults do  Many older men and women need calcium supplements  A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? - Correct answer Pressure ulcer should the nurse recommend? - Correct answer Fresh fruit and whole wheat toast  A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? - Correct answer Hypotension  Elevated temperature  Poor skin turgor  While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? - Correct answer Lower the enema fluid container  A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? - Correct answer WARM the enema solution prior to instillation  Position the client on the left side with the right leg flexed forward  Lubricate the rectal tube or nozzle  A nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of 3 vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? - Correct answer Decrease or avoid caffeine  Avoid drinking alcohol  A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? - Correct answer Check to see whether the catheter is patent  A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take - Correct answer Discard the first voiding  A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? - Correct answer Frequent sexual intercourse  Location of the urethra in relation to the anus  Frequent catheterization  A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? - Correct answer Have the client record urination times  Gradually increase the urination intervals  Remind the client to hold urine until the next scheduled urination time  A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? - Correct answer Make sure only one person speaks at a time  Allow plenty of time for the client to respond  Use brief sentences with simple words  A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? - Correct answer Provide a private room and limit stimulation  A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? - Correct answer Weber test showing lateralization to the right ear  Rinne test showing less time for air and bone conduction  A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to further risk for ototoxicity? - Correct answer Furosemide  Ibuprofen  A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? - Correct answer I take the batteries out of my hearing aids when I take them off at night  A nurse is caring for a client who is 1 day postop following a knee arthroplasty. The client states his pain level is 10 on a scale from 0 to 10. After reviewing the client's medication record, which of the following medications should the nurse administer? - Correct answer Morphine 2 mg/IV  A nurse is teaching a client about taking multiple oral medications at home to include the time-release capsules, liquid medications, enteric-coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? - Correct answer I will eat two crackers with pain pills  A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? - Correct answer Flush the tube before and after each medication  A nurse is preparing to inject heparin subcutaneously for a client who is postop. Which of the following actions should the nurse take? - Correct answer Select a site on the client's abdomen  A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands the proper technique? - Correct answer I will gently apply pressure with my finger to the front part of my ear after putting in the drops.  A nurse prepares an injection of morphine to a client who reports pain. Prior to administering the medication, the nurse assists another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take? - Correct answer Offer to assist the client who needs the bedpan  A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medication? - Correct answer 0905  0840  (Within a 30 min radius)  A nurse is working with a newly licensed nurse who is administering medication to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? - Correct answer Checking with the provider when a single dose requires administration of multiple tablets  A nurse educator is teaching a module about safe medication administration to newly licensed nurses identify as an indication that one of the group understands how to implement medication therapy? (Select all that apply) - Correct answer I will observe for side effects  I will monitor for therapeutic effects  I will refuse to give a medication if I believe it is unsafe  (100mg/1cap) = (200mg/x cap)  x = 2 capsules!  To promote adherence with self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? - Correct answer Place pills in daily pill holders  Ask for liquid forms if the client has difficulty swallowing pills  Ask a relative to assist periodically  A young adult client in a provider's office tells the nurse that she uses fasting for several days each week to help control her weight. The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? - Correct answer Increasing the protein-binding response  A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects the children? - Correct answer Lower BP  Higher body water content  Increased absorption of topical medications  A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? - Correct answer Take each dose right after breastfeeding  A nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statements should the nurse make? - Correct answer Your provider can prescribe medication for nausea if you need it?  A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? - Correct answer Hold the hand in a dependent position prior to the puncture  Place the puncturing device perpendicular to the site  Prick the outer edge of the fingertip for the blood sample  A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? - Correct answer Restlessness  Tachypnea (abnormally rapid breathing)  Confusion  Pallor  A provider is discharging a client who  has a prescription for home oxygen  therapy via nasal cannula. Client  and family teaching by the nurse  should include which of the following  instructions? (Select all that apply.) o Apply petroleum jelly around  and inside the nares.  B. Remove the nasal cannula  during mealtimes.  C. Check the position of  the cannula frequently.  D. Report any nasal stuffiness,  nausea, or fatigue.  E. Post "No Smoking" signs  in a prominent location. - Correct answer C. Check the position of the cannula frequently  D. Report any nasal stuffiness, nausea, or fatigue  E. Post "No Smoking" signs in a prominent location  A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? - Correct answer Assist the client to Fowler's position  A nurse is preparing to perform endotracheal suction for a client. The nurse should follow which of the following guidelines? - Correct answer Apply suction while withdrawing the catheter  Use a new catheter for each suctioning attempt  Limit total suction time to 5 minutes  A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? - Correct answer Apply the oxygen source loosely if the SpO2 decreases during the procedure  Use surgical asepsis to remove and clean the inner cannula  Clean the outer surfaces in a circular motion from the stoma site outwards  A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? o "Water helps clear the tube so it doesn't get clogged." o "Flushing helps make sure the tube stays in place." o "This will help you get enough fluids." o "Adding water makes the formula less concentrated." - Correct answer Water helps clear the tube so it doesn't get clogged  A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? - Correct answer STOP THE FEEDING  A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? - Correct answer Verify the placement of the NG tube  A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? - Correct answer Auscultate bowel sounds  Assist the client to an upright position  Test the pH of gastric aspirate  A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? - Correct answer Review a signal the client can use if feeling any distress  Lay a towel across the client's chest  A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He