Nursing Care for Clients: Promoting Self-Reliance and Preventing Complications, Exams of Nursing

Download Nursing Care for Clients: Promoting Self-Reliance and Preventing Complications and more Exams Nursing in PDF only on Docsity! Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons instead of property. Behaving in a way that a reasonable person with the same education would not is the definition of The application of force to another person without lawful justification. Correct3 of students nationwide answered this question correctly.65% Confidence: Nailed it 1130037135 Cleaning a newborn immediately after delivery. Correct2 Emptying a portable wound drainage system. Correct3 Nurse behavioural practice and ethics. Download, 1 A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? 1 Maligning a person's character while threatening to do bodily harm. 2 A legal wrong committed by one person against property of another. 4 Behaving in a way that a reasonable person with the same education would not. View Topics Stats Issue with this question? Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1 Giving a back rub. Personal protective equipment (PPE) should be used because the newborn is covered with amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub; there is no indication that the nurse is in contact with body secretions. PPE is not necessary when conducting an interview because it is unlikely that the nurse will come in contact with the client's body fluids. PPE is not necessary when obtaining the blood pressure of a client, Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive of students nationwide answered this question correctly.60% Confidence: Nailed it 1130036514 Reinforce success in tasks accomplished. Correct3 of students nationwide answered this question correctly.65% Confidence: Pretty sure 1130044704 4 Interviewing a client in the emergency department. 5 View Topics Stats Issue with this question? A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence? 1 Establish long-range goals for the client. 2 Identify errors that the client can correct. 4 Demonstrate ways to promote self-reliance. View Topics Stats Issue with this question? Percussion (chest physiotherapy) loosens pulmonary secretions by mechanical means. This is accomplished by vibrations over the lung fields on the client's posterior, anterior, and lateral chest. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate Health care provider, because of total responsibility for the child's health and treatment regimen Loosen pulmonary secretions. Correct3 of students nationwide answered this question correctly.70% Confidence: Pretty sure 1130035441 Nurse, because failure to further question the health care provider about the child's status placed the child at risk Correct3 A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 1 Relieve bronchial spasm. 2 Increase depth of respirations. 4 Expel carbon dioxide from the lungs. View Topics Stats Issue with this question? A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurological impairment. Legally, who is responsible for the child's injury? 1 Health care provider, because this decision took precedence over the nurse's concern 2 It is the nurse's responsibility to foresee potential harm and prevent risks by acting as a client advocate. This is not acceptable as a rationale for inaction. The nurse and health care provider share interdependent roles in the assessment and care of clients. High temperatures are common in children but are nonetheless a The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and Neither, because high fevers are common in children and the health care provider had little cause for concern of students nationwide answered this question correctly.71% Confidence: Nailed it 1130045532 Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving. Correct4 of students nationwide answered this question correctly.68% Confidence: Pretty sure 1130049034 4 View Topics Stats Issue with this question? On the third postoperative day following a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? 1 Explain why there is a need to increase activity. 2 Emphasize that with a prosthesis, there will be a return to the previous lifestyle. 3 Appear cheerful and non-critical regardless of the client's response to attempts at intervention. View Topics Stats Issue with this question? Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints due to wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles due to a lack of physical activity or a neurological or musculoskeletal Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Contracture Correct4 Time Incorrect2 While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 1 The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? 1 Soap 3 Water Correct4 Friction The meat provides proteins and the fruit provides vitamin C; both promote wound healing. Although meatloaf provides protein, tea does not provide vitamin C. Chicken soup and a baked apple do not meet the client's need for protein or vitamin C. Chicken soup and buttered bread do not meet the client's need for of students nationwide answered this question correctly.68% Confidence: Just a guess 1140375736 Meatloaf and tea Incorrect1 of students nationwide answered this question correctly.68% Confidence: Just a guess 1140359979 STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question. View Topics Stats Issue with this question? A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends: Correct2 Meatloaf and strawberries 3 Chicken soup and baked apple 4 Chicken soup and buttered bread View Topics Stats Issue with this question? A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to: Correct1 Space activities throughout the day Spacing activities encourages maximum functioning within the limits of the client's strength and endurance. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Teaching the limitations imposed by the disorder is necessary for lifelong psychological adjustment, but does not address the client's concerns at this time. Having a member of the family stay and give the client support should be permitted if requested by the client or family, but does not Fiber promotes passage of residue through the intestine, thereby preventing constipation. Constipation causes straining at stool; this increases intraluminal pressure, which can precipitate diverticulitis or perforation of diverticulum. The other diets are not indicated for diverticulosis. Have a family member stay at the bedside to give the client support Incorrect4 of students nationwide answered this question correctly.64% Confidence: Just a guess 1140387132 Low-fat Incorrect1 2 Restrict activities and encourage bed rest 3 Teach the client about limitations imposed by the disorder View Topics Stats Issue with this question? An older client's colonoscopy reveals the presence of extensive diverticulosis. What type of diet should the nurse encourage the client to follow? Correct2 High-fiber 3 High-protein 4 Low-carbohydrate 1 Pain with ureteral stones is caused by spasm and is excruciating and intermittent; it follows the path of the ureter to the bladder. Pain is spasmodic and excruciating, not boring. Pain intensifies as the calculus lodges in the ureter and spasms occur in an attempt to dislodge it. Spasmodic pain on the left side that radiates to the suprapubis is typical of pain caused by a stone in the renal pelvis. STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter. That occurs with each urination and is located at the level of the kidneys Incorrect2 of students nationwide answered this question correctly.61% Confidence: Pretty sure 1140399068 Incorrect2 A client with a left ureteral calculus is scheduled for a transurethral ureterolithotomy. During the preoperative assessment, the nurse expects the client to report pain: 1 That is a boring-type pain that is located in the left flank 3 That is dull and constant and located in the costovertebral angle Correct4 That is spasmodic and located in the left side and radiating to the suprapubic area View Topics Stats Issue with this question? A client is cautioned to avoid vitamin D toxicity while increasing protein intake. Which nutrient selected by the client indicates to the nurse that the dietary teaching is understood? Correct1 Tofu Eggnog 3 Cottage cheese 4 Powdered whole milk Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds then release to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2 + indicates a 4 mm depression. A Steamed lobster of students nationwide answered this question correctly.47% Confidence: Just a guess 1130040431 2+ Incorrect2 of students nationwide answered this question correctly.68% Confidence: Pretty sure 1135028812 The temperature during steaming is never high enough or sustained long enough to kill microorganisms. Processing destroys the virus. Because of the extremely high temperature, broiling sufficiently destroys the virus. Baking will destroy the virus. STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If View Topics Stats Issue with this question? A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as: 1 1+ 3 3+ Correct4 4+ View Topics Stats Issue with this question? Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements. "Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion." Incorrect3 of students nationwide answered this question correctly.63% Confidence: Pretty sure 1140359907 45 degrees Incorrect2 A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant? 1 "Because he tires easily, it's best to have him lying in bed while he is being fed." 2 "Hold him in a horizontal position and feed him slowly to help prevent aspiration." Correct4 "Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air." View Topics Stats Issue with this question? A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at an angle of: Correct1 30 degrees 3 60 degrees 4 90 degrees An orange contains only trace amounts of sodium. One cup of ice cream contains approximately 115 mg of sodium. One cup of celery contains approximately 106 mg of sodium. Four peanut butter cookies contain 142 mg of sodium. of students nationwide answered this question correctly.76% Confidence: Pretty sure 1140346622 Celery sticks Incorrect2 of students nationwide answered this question correctly.54% Confidence: Nailed it 1140379051 Incorrect1 Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Forty- five degrees, 60 degrees, and 90 degrees raise the head of the bed too high, which contributes to the client sliding down in bed. View Topics Stats Issue with this question? A client is receiving a 2-gram sodium diet. The family asks whether they can bring snacks from home. The nurse suggests that they bring foods low in sodium such as: 1 Ice cream Correct3 Fresh orange wedges 4 Peanut butter cookies View Topics Stats Issue with this question? A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan related to how to prevent thrombophlebitis? Perform leg exercises 2 Sit with the knees flexed 3 Clients with quadriplegia do not have the muscle innervation, strength, or balance needed for ambulation. Bracing and crutch- walking require muscle strength and coordination that an individual with quadriplegia does not have. Orthostatic hypotension can be prevented by a gradual assumption of the upright position and does not necessarily require a wheelchair. Quadriplegia refers to paralysis The nurse should become informed about the cultural eating patterns of clients so that foods containing the essential nutrients that are part of these dietary patterns may be included in the diet. Fluid retention is only one component of weight gain; growth of the fetus, placenta, breasts, and uterus also contributes to weight gain. The need for calories and nutrients increases during pregnancy. Pregnancy diets are not specific; they are composed of the essential nutrients. They have the strength in the upper extremities for self-transfer. of students nationwide answered this question correctly.56% Confidence: Nailed it 1135025178 Different cultural groups favor different essential nutrients. Correct2 It prepares them for wearing braces. 3 It assists them in overcoming orthostatic hypotension. 4 View Topics Stats Issue with this question? Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women? 1 Most weight gain is caused by fluid retention. 3 Dietary allowances should not increase throughout pregnancy. 4 Pregnant women must adhere to a specific pregnancy dietary regimen. Rye should be avoided because it is irritating to the gastrointestinal mucosa. Oats should be avoided because they are irritating to the gastrointestinal mucosa. Products containing wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice; therefore, it does not have to be avoided. Gluten is not found in corn; therefore, it does not have to be avoided. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and of students nationwide answered this question correctly.61% Confidence: Nailed it 1140387198 Rye Correct1 Oats Correct2 Wheat Correct5 of students nationwide answered this question correctly.48% View Topics Stats Issue with this question? A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? (Select all that apply.) 3 Rice 4 Corn Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing infection. Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma created on the abdomen. Stomatitis does not cause diarrhea or fluid loss. The abdomen is not involved; stomatitis is an inflammation of the oral Confidence: Just a guess 1130044741 Provide frequent saline mouthwashes. Correct1 of students nationwide answered this question correctly.61% Confidence: Nailed it 1140390833 View Topics Stats Issue with this question? A client is experiencing stomatitis as a result of chemotherapy. Which nursing action is most appropriate when caring for this client? 2 Use karaya powder to decrease irritation. 3 Increase fluid intake to compensate for accompanying diarrhea. 4 Provide meticulous skin care of the abdomen with an antiseptic. View Topics Stats Issue with this question? A nurse is monitoring a client with renal failure for signs of fluid excess. Which finding does the nurse identify as inconsistent with fluid excess? 1 Increased weight 2 Distended neck veins Most children with bilateral clubfeet are eventually able to walk without much difficulty. Prosthetic devices generally are not indicated. Serial casting with cast changes every week is usually successful. If serial casting is not effective, surgical intervention may be necessary. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. "We'll have to have the baby fitted with prosthetic devices before he'll be able to walk." Correct4 A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required? 1 "We'll have to start serial casting right away." 2 "The casts will have to be changed every week." 3 "The baby may have to have surgery if the problem's not fixed in a few months." 1 A fter surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." The nurse should: 1 Notify the health care provider 2 Use distraction techniques 3 Medicate the client as prescribed Clients with tuberculosis tend to have anorexia and lose weight; small, frequent, high- calorie meals encourage food intake and provide calories for weight gain. Liquid protein supplements are not necessary; protein and other nutrients can be obtained through natural foods. Low proteins are contraindicated; increased protein intake is necessary for tissue building. Meals low in calories but high in carbohydrates are impossible; carbohydrates contain calories. Perform a complete pain assessment Correct4 of students nationwide answered this question correctly.64% Confidence: Nailed it 1140373280 Small, frequent, high-calorie meals Correct2 of students nationwide answered this question correctly.75% Confidence: Nailed it 1140397102 A complete assessment must be performed to determine the location, characteristics, intensity, and duration of the pain. The pain may be incisional, result from a pulmonary embolus , or be caused by neurovascular trauma to the affected leg, and the intervention for each is different. Notifying the health care provider, using distraction techniques, and medicating the client as prescribed may be done after a complete assessment reveals that this is the appropriate View Topics Stats Issue with this question? A client with pulmonary tuberculosis discusses the dietary plan with the nurse. The nurse expects that the type of diet that will be prescribed for the client is: 1 Liquid protein supplements 3 Foods high in calories and low in protein 4 Meals low in calories but high in carbohydrates View Topics Stats Issue with this question? A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates adequate tissue perfusion to vital organs? A urinary output rate of 30 mL/hour is considered adequate for perfusion of the kidneys, heart, and brain. A central venous pressure reading of 2 mm Hg indicates hypovolemia. A baseline pulse rate of 120 that decreases to 110 beats/min within a 15-minute period and a baseline blood pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period indicate improvement but not necessarily Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 L of fluid weighs about 2.2 lb. Visual inspection is subjective and generally inaccurate. Measuring intake and output is not as accurate as daily weights; fluid may be trapped in the third compartment. Monitoring of electrolyte values is unreliable; they may or may not be altered with Urinary output of 30 mL in an hour Correct1 of students nationwide answered this question correctly.69% Confidence: Nailed it 1143260284 Correct1 of students nationwide answered this question correctly.71% 2 Central venous pressure reading of 2 mm Hg 3 Baseline pulse rate of 120 that decreases to 110 beats/min within a 15-minute period 4 Baseline blood pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period View Topics Stats Issue with this question? A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child's history reveals a 5-lb weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child's edema? Weighing daily 2 Observing body changes 3 Measuring intake and output 4 Monitoring electrolyte values Small, frequent feedings with adequate rest periods in between may improve the infant's intake at each feeding; infants with tetralogy of Fallot become extremely fatigued while suckling. Positioning the child with the head elevated facilitates respiration; an infant cardiac seat, similar to a car seat, helps maintain the child in the semi-Fowler position. As a means of reducing the cardiac workload, excessive fluids usually are not offered, and fluids may even be restricted. The head circumference is not an important assessment for infants with congenital heart disease; daily head measurements should be taken for infants with hydrocephaly. Providing small, frequent feedings. Correct1 of students nationwide answered this question correctly.66% Confidence: Nailed it 1140407837 Regular diet with vitamins and minerals Correct4 What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure? 2 Positioning the child flat on the back 3 Encouraging nutritional fluids often. 4 Measuring the head circumference daily. View Topics Stats Issue with this question? A client who has intermittently been having painful, swollen knee and wrist joints during the past three months is diagnosed with rheumatoid arthritis. What type of diet should the nurse expect the health care provider to prescribe? 1 Salt-free, low-fiber diet 2 High-calorie, low-cholesterol diet 3 High protein diet with minimal calcium The client who is confined to bed should be encouraged to move in bed to prevent prolonged pressure on any one skin surface. Massaging bony prominences increase the risk of skin breakdown. Although sheepskin material allows air to circulate under the client, it does not prevent prolonged pressure. Range-of-motion exercises move joints to prevent contractures; they do not relieve prolonged pressure. of students nationwide answered this question correctly.55% Confidence: Pretty sure 1140359909 Encouraging the client to move around as much as possible Correct4 There are no dietary restrictions, but iron and vitamins should be encouraged to treat any underlying nutritional deficiencies. A salt-free, low-fiber diet is not indicated. A high-calorie diet will increase the client's weight; this is contraindicated because it will increase the strain on weight-bearing joints. A balanced diet should fulfill nutritional needs; there is no need to increase protein or restrict calcium. Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study View Topics Stats Issue with this question? The nurse is providing care for a client that is on bed rest. The nurse can prevent skin breakdown for this client by: 1 Massaging the bony prominences 2 Maintaining a sheepskin pad under the client 3 Promoting range-of-motion activities 1 Deep breathing exercises are an effective intervention in controlling pain; this is a positive coping skill. Muscle relaxation techniques generally include muscle contraction and then relaxation, which may increase the pain. Active range-of- motion exercises may increase the pain. Understanding important aspects of wound care will not reduce pain; health teaching should be initiated before, not Although oatmeal is a soluble fiber, whole milk is high in saturated fat and should be avoided. Olive oil contains unsaturated fat. Most fish have a low fat content; fruit does not contain fat. Soluble fiber helps to lower cholesterol; skim milk does Deep breathing exercises Correct1 of students nationwide answered this question correctly.72% Confidence: Nailed it 1140392960 Correct1 A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes? 2 Progressive muscle relaxation 3 Active range-of-motion exercises 4 Important elements of wound care View Topics Stats Issue with this question? A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction? Whole milk with oatmeal 2 Garden salad with olive oil 3 Tuna fish with a small apple 4 Soluble fiber cereal with skim milk Fruits contain less natural sodium than do other foods. Milk is higher in natural sodium than is fruit. Meat is higher in natural sodium than is fruit. Vegetables are higher in natural sodium than is fruit. The goal is to prevent constipation to limit trauma to the surgical site. Breast milk produces a softer stool. Oral feedings are started soon after surgery. Placing the infant in the Trendelenburg position will not promote healing in the anal area and may impede respiratory excursion. Positioning the infant supine with the head of the crib elevated will increase pressure in the perianal area, which could Fruits Correct3 of students nationwide answered this question correctly.51% Confidence: Nailed it 1143238976 Encouraging continuation of breastfeeding Correct2 A nurse provides dietary teaching about a low-sodium diet for a client with hypertension. Which nutrient selected by the client indicates an understanding about foods that are low in natural sodium? 1 Milk 2 Meat 4 Vegetables View Topics Stats Issue with this question? A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include? 1 Withholding oral feedings for several days 3 Placing the infant in the Trendelenburg position 4 Positioning the infant supine with the head of the crib elevated Cholecystitis is often accompanied by intolerance to fatty foods, including fried foods and butter. Because nuts and popcorn have a high fiber content, they cause flatulence and pain for clients with lower intestinal problems, such as diverticulosis. Meatloaf and baked potato contain less fat than do fried foods or butter. Neither chocolate nor boiled seafood contains as much fat as fried chicken or butter. One ounce (oz) equals approximately 30 mL. The client drank a total of 21.5 oz; multiply 21.5 × 30, which yields 645 mL. 55%of students nationwide answered this question correctly. 1140358054 Confidence: Just a guess Fried chicken and buttered corn Correct4 57%of students nationwide answered this question correctly. 1140390845 Confidence: Nailed it 59%of students nationwide answered this question correctly. 1130045978 Confidence: Nailed it View Topics Stats Issue with this question? A client experiences occasional right upper quadrant pain attributed to dyspepsia. The nurse is providing discharge instructions, including a list of foods that cause dyspepsia. The list should include: 1 Nuts and popcorn 2 Meatloaf and baked potato 3 Chocolate and boiled shrimp View Topics Stats Issue with this question? A client drank 7.5 oz of orange juice, 6 oz of tea, and 8 oz of eggnog. How many milliliters of fluid were consumed by the client? Record your answer using a whole number. mL View Topics Stats High Fowler's position elevates the clavicles and helps the lungs to expand, thus easing respirations. The other options do not promote more comfortable Withholding food reduces the need for intestinal activity, which rests the intestines and minimizes diarrhea and the loss of fluid. Although intravenous therapy will be started for rehydration and to correct electrolyte imbalances, this is not the reason High-Fowler's position using the bedside table as an arm rest Correct4 Allow the intestinal tract to rest Correct2 Issue with this question? A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? 1 Side lying position with head elevated 45 degrees 2 Sim's position with head elevated 90 degrees 3 Semi-Fowler's position with legs elevated 1 A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that this is necessary to: 1 Correct electrolyte imbalances 3 Determine the cause of the diarrhea 4 Prevent perianal irritation from the diarrhea A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain, and edema. The fracture will be reduced by surgery; Buck's traction is a temporary measure before surgery. Moving the leg away from the midline will not keep the leg in alignment; it is not the purpose of Buck's traction. External rotation of the femur may still occur with Buck's traction. of students nationwide answered this question correctly.52% Confidence: Nailed it 1140355314 Immobilize the fracture Correct2 of students nationwide answered this question correctly.62% Confidence: Nailed it 1140409028 View Topics Stats Issue with this question? A client suffered an injury to the leg as a result of a fall. X-ray films indicate an intertrochanteric fracture of the femur. The client will be placed in Buck's traction until surgery is performed. When considering the client's plan of care, the nurse recalls that the primary purpose of Buck's traction is to: 1 Reduce the fracture 3 Maintain abduction of the leg 4 Eliminate rotation of the femur View Topics Stats Issue with this question? A nurse is caring for a client with acute kidney failure who is receiving a protein- restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the client's questions? 1 A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. 2 The amount of protein permitted in the diet (usually less than 50 g) depends on the extent of kidney function; excess protein causes an increase in urea concentration, which should be avoided Adequate calories are provided to prevent tissue catabolism, which also results in an increase in metabolic waste products. In kidney failure the kidneys are unable to eliminate the waste products of a high protein diet. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids. Vitamin E hinders the oxidative breakdown of structural lipid membranes in body tissues, which is caused by free radicals in the cells. Vitamin A assists in the formation of visual purple needed for night vision. Vitamin C is used for formation of collagen, which is important for maintaining capillary strength, promoting wound healing, and resisting infection. Vitamin B1 is necessary for protein and fat metabolism and for functioning of the nervous system. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. Correct3 of students nationwide answered this question correctly.68% Confidence: Nailed it 1140397134 E Correct4 of students nationwide answered this question correctly.59% Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. 4 Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein. View Topics Stats Issue with this question? An older adult tells the nurse, "I read about a vitamin that may be related to aging because of its effect on the structure of cell walls. I wonder whether it is wise to take it." The nurse concludes the client probably is referring to: 1 A 2 B1 3 C Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet. Confidence: Nailed it 1140402606 Spinach salad Correct2 Incorrect1 View Topics Stats Issue with this question? A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? 1 Poached eggs 3 Sweet potatoes 4 Cheese sandwich 1 A client who recently experienced a brain attack (CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation? Presence of distention 2 Baked chicken is relatively low in calcium. Roast beef and mashed potato have moderate amounts of calcium. Pudding is made with milk and is high in calcium. Cheese is high in calcium. Ice cream is made with milk and is high in calcium. of students nationwide answered this question correctly.62% Confidence: Nailed it 1140374351 Baked chicken Correct1 Chocolate pudding Incorrect2 Roast beef with mashed potato Correct4 of students nationwide answered this question correctly.58% Confidence: Pretty sure 1130046851 client feels tired. Twisting exercises are contraindicated because they exert excessive pressure on the operative site. View Topics Stats Issue with this question? A nurse teaches a client with calcium-based renal calculi about foods that can be eaten on a low-calcium diet (400 mg/day). The nurse concludes that the teaching was effective when the client selects what food items from the menu? (Select all that apply.) 3 Salmon loaf with cheese sauce 5 Vanilla ice cream with chocolate syrup View Topics Stats Issue with this question? A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? 1 Prune juice does not require a health practitioner order and helps to promote bowel movement because it contains sorbitol, which increases water retention in feces. Administration of mineral enema requires an order from a health care provider. Encouraging the client's fluid intake by offering one cup of fluid every hour is helpful in preventing constipation but not as effective in resolving constipation as a prune Four pregnancies = G (gravida ) 4. One pregnancy that ended at 38 weeks = T (term) 1. One pregnancy that ended at 32 weeks = P (preterm) 1. One pregnancy that ended at 18 weeks = A (abortion) 1. One set of twins and a singleton = L (living) 3. Offer one cup of fluid every hour. Incorrect2 of students nationwide answered this question correctly.68% Confidence: Nailed it 1135202881 Incorrect2 of students nationwide answered this question correctly.60% Administer a mineral oil enema. 3 Manually remove fecal impactions. Correct4 Offer a cup of prune juice. View Topics Stats Issue with this question? Using the five-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks. 1 G4, T2, P1, A1, L2 G4, T1, P2, A1, L1 Correct3 G4, T1, P1, A1, L3 4 G4, T2, P1, A1, L1 View Topics 1 130043540 Sodium absorbs water in the kidneys' renal tubules. When dietary intake of sodium is decreased, water is not reabsorbed and edema is reduced. A decrease in sodium will prevent the reabsorption of water. Furosemide stimulates the loop of Henle to inhibit the reabsorption of sodium and chloride at the proximal and distal tubules. Adequate hydration is the major factor that diminishes the thirst response. A low- sodium diet will help move fluid from the interstitial compartment to the 540 mL is a correct calculation. 4 ounces apple juice x 30 mL/ounce = 120 mL, 6 oz tea x 30 mL/ounce = 180 mL, and 240 mL chicken broth provide a total of 540 mL that the client has ingested. Cause fluid to move toward the interstitial compartment Incorrect4 68%of students nationwide answered this question correctly. 1140375795 Confidence: Just a guess 64%of students nationwide answered this question correctly. 1135006418 Confidence: Pretty sure Confidence: Nailed it Stats Issue with this question? The health care provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to: 1 Chemically stimulate the loop of Henle 2 Diminish the thirst response of the client Correct3 Prevent reabsorption of water in the distal tubules View Topics Stats Issue with this question? A client has 4 ounces of apple juice, 6 ounces of tea, and 240 mL of chicken broth. The nurse calculates that the client ingested how many mL of fluid? Record your answer using a whole number. mL View Topics Stats Issue with this question? Radiodermatitis occurs three to six weeks after the start of treatment. The word "burn" should be avoided because it may increase anxiety. Emollients are contraindicated; they may alter the calculated x-ray route and injure healthy tissue. The response about the client's family does not address the client's Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy. "Your family must have had experience with radiation therapy." Incorrect4 of students nationwide answered this question correctly.68% Confidence: Nailed it 1140402633 "You are right because they may have a negative impact on people's health." Incorrect4 of students nationwide answered this question correctly.72% Correct2 "A localized skin reaction usually occurs." 3 "A daily application of an emollient will prevent a burn." View Topics Stats Issue with this question? A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 1 "Hospital policies should put a stop to this." 2 "Everyone should conform to the prevailing culture." Correct3 "Nontraditional approaches to health care can be beneficial." View Topics Certain diagnostic tests (e.g., CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks involved with surgery. Feelings will not be dispelled by telling the client not to worry; it also blocks further communication. Surgery poses a risk despite test results. Lack of knowledge without a statement of plans to obtain the information suggests incompetence on the part of the nurse. Confidence: Nailed it 1130039621 "They determine whether surgery will be safe." Incorrect3 of students nationwide answered this question correctly.61% Confidence: Nailed it 1130047602 White blood cell (WBC) count of 8200/mm3 Incorrect1 Stats Issue with this question? A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? 1 "Don't worry; these tests are routine." Correct2 "They are done to identify other health risks." 4 "I don't know; your health care provider prescribed them." View Topics Stats Issue with this question? The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: 2 Bilateral 3+ pitting pedal edema Correct3 Oral temperature of 101.3º F An elevated temperature of 101.3° F is most indicative of a systemic infection. A white blood cell (WBC) count of 8200/mm3 is within the WBC normal range of 5000- 10,000/mm3. Pedal edema is generally not related to an infectious process. Pale skin and nail beds may be related to an infectious process but not necessarily. Because the client is not certified as incompetent, the right of informed consent is retained. The client can sign the consent, but the client's signature requires only one witness. Because there is no evidence of incompetence, the client should sign Pale skin and nail beds of students nationwide answered this question correctly.58% Confidence: Nailed it 1130035486 Ensure that the health care provider and the psychiatrist sign for the surgery because it is an emergency procedure. Incorrect2 of students nationwide answered this question correctly.68% Confidence: Just a guess 1130047674 4 View Topics Stats Issue with this question? A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? 1 Have two nurses witness the client signing the operative consent form. Correct3 Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. 4 Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit. View Topics Stats Issue with this question? A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? The appropriate site to obtain a urine specimen for a patient with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, as the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling In this situation being aware that a client is overmedicating and taking no action can be considered an act of euthanasia on the part of the home care nurse. Implementing a "do not resuscitate" order, abiding by the decision of a living will signed by the client's family, and encouraging the client to consult an attorney are all appropriate actions for a home care nurse. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so. catheter insertion site of students nationwide answered this question correctly.66% Confidence: Nailed it 1130047659 Knowing that a dying client is overmedicating and not acting on this information. Correct4 of students nationwide answered this question correctly.73% Confidence: Nailed it 1130047683 3 urinary drainage bag 4 View Topics Stats Issue with this question? Which action by a home care nurse would be considered an act of euthanasia? 1 Implementing a "do not resuscitate" order in the home health setting. 2 Abiding by the decision of a living will signed by the client's family. 3 Encouraging a client to consult an attorney to document and assign a power of attorney. View Topics The principle of autonomy relates to the freedom of a person to form his or her own judgments and actions. The nurse promotes autonomy nonjudgmentally so as not to infringe on the decisions or actions of others. Justice means to be righteous, equitable, and to act or treat fairly. Beneficence relates to the state or act of doing good, being kind and charitable. It also includes promotion of well-being and abstaining from the injuring of others. Paternalism encompasses the practice of governing people in a fatherly manner, especially by providing for their needs without infringing on their rights or responsibilities. Test-Taking Tip: After choosing an answer, go back and reread the question Autonomy Correct2 of students nationwide answered this question correctly.72% Confidence: Nailed it 1130035467 Correct2 Stats Issue with this question? A nurse who promotes freedom of choice for clients in decision-making best supports which principle? 1 Justice 3 Beneficence 4 Paternalism View Topics Stats Issue with this question? A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1 Limits had to be set to control the child's crying. The child had a right to remain in the room with the other children. Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation. Segregation of the child for more than half an hour was too long a period of time. of students nationwide answered this question correctly.57% Confidence: Nailed it 1130049025 Papules Correct3 of students nationwide answered this question correctly.66% Confidence: Nailed it 1130038735 3 The child had to be removed because the other children needed to be considered. 4 View Topics Stats Issue with this question? The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? 1 Erosions 2 Macules 4 Vesicles View Topics Stats Issue with this question? A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? All of these laboratory tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status . Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, Arterial blood gas Correct3 of students nationwide answered this question correctly.68% Confidence: Nailed it 1130049079 Assault is a threat or an attempt to do violence to another. Assault implies harm to persons rather than property. A legal wrong committed against the public that is punishable by state law is too broad to describe assault. Application of force to another person without lawful justification is the definition of battery. 1 The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1 Red blood cell count 2 Sputum culture 4 Total hemoglobin View Topics Stats Issue with this question? What should the nurse include in dietary teaching for a client with a colostomy? 1 Liquids should be limited to 1 L per day. Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and also produce stools that are manageable, depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Food high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience. The health care provider needs to be aware of the reason for the client's lack of response to the medication so that an alternate treatment plan or financial assistance can be arranged (e.g., go to The National Council on the Aging web site [BenefitsCheckUpRx] to establish whether the client is eligible for assistance from any community, state, or federal programs or from the drug company). A health care provider may prefer the proprietary form of the The diet should be adjusted to include foods that result in manageable stools. Correct4 of students nationwide answered this question correctly.66% Confidence: Nailed it 1130039631 Correct3 2 Non-digestible fiber and fruits should be eliminated. 3 A formed stool is an indicator of constipation. View Topics Stats Issue with this question? A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? 1 Ask the pharmacist to provide a generic form of the medication. 2 Encourage the client to acquire the medication over the internet. Inform the health care provider of the inability to afford the medication. 4 Suggest that the client purchase insurance that covers prescription medications. Frequent swallowing may indicate bleeding in the posterior pharynx. Oral dryness causes thirst, not an increase in swallowing. Frequent swallowing is not a normal response to rhinoplasty or analgesics/anesthesia. Test-Taking Tip: If the question asks for an immediate action or response, all the answers may be correct, so base your selection on identified priorities for action. of students nationwide answered this question correctly.73% Confidence: Just a guess 1130045969 Bleeding posterior to the nasal packing Correct4 of students nationwide answered this question correctly.61% medication. To ask the pharmacist to provide a generic form of the medication is unsafe. To recommend that the client obtain a generic form of the medication is not within the legal role of the nurse, unless the health care provider documents that this is acceptable. Medications purchased over the internet may be illegally imported, counterfeit, expired, or contaminated and therefore should be avoided. Although some prescription insurance plans may help to reduce the cost of some medications, the client may not be able to afford the insurance. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of this text over an extended period of time ensures your understanding of the mechanics of the examination and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you View Topics Stats Issue with this question? The nurse is caring for a client that underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely caused from: 1 A normal response to the analgesic 2 Oral dryness caused by nasal packing 3 An adverse reaction to anesthesia View Topics 1 130044729 Cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage. Milk, cheese, and coffee, in moderation, should not cause excessive gas problems. The client with a new colostomy should slowly introduce new foods into the diet to test toleration. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process. Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance Cabbage Correct4 of students nationwide answered this question correctly.65% Confidence: Nailed it 1130049037 Assess the pin sites at least every shift and as needed. Correct2 1 Milk 2 Cheese 3 Coffee View Topics Stats Issue with this question? Which nursing intervention is most appropriate for a client in skeletal traction? 1 Add and remove weights as the client desires. 3 Ensure that the knots in the rope are tied to the pulley. 4 Perform range of motion to joints proximal and distal to the fracture at least once a day. Research suggests that children who are spanked tend to use aggressive behavior; as they grow older they learn their own behavior through their parents' behavior. Age is not significant in terms of the effectiveness of spanking. Research studies contradict the assertion that spanking is an effective disciplinary technique. STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend 7 hours sleeping and 3 hours studying than to cut sleep to 6 hours and study 4 hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to of students nationwide answered this question correctly.66% Confidence: Nailed it 1143221985 "Spanking is strongly suggestive of negative role modeling." Correct2 joints except the ones proximal and distal to the fracture, since this area is immobilized by the skeletal traction to promote healing and prevent further injury View Topics Stats Issue with this question? What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique? 1 "Effectiveness depends on the child's age." 3 "Spanking may be the only option when no other technique works." 4 "Research studies have shown it to be an effective disciplinary technique." 1 A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics. Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." Take the temperature Correct3 of students nationwide answered this question correctly.56% Confidence: Nailed it 1140351421 1 Encourage fluids 2 Administer oxygen 4 Collect a sputum specimen View Topics Stats Issue with this question? An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 The fetus of a heroin-addicted mother is at risk for serious complications such as hypoxia and meconium aspiration. It is important to notify the healthcare provider of the client's heroin use, because this information will influence the care of the client and newborn. This information is used only in relation to the client's care. With the client's consent, it may be shared with other social service or health agencies that become involved with the client's long-term care. The nurse manager of the unit may be notified as it relates to the care of the client and her newborn. Client information is confidential and only necessary staff should be privileged to such information. Hospital security would only be notified if actual illicit substances Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening and the client can wait for care. A woman in active labor should be assessed immediately because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately. Alert the hospital security department because heroin is an illegal substance. of students nationwide answered this question correctly.67% Confidence: Nailed it 1140400075 Older adult male with a partially amputated finger Correct3 4 View Topics Stats Issue with this question? The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1 Multipara in active labor 2 Middle-aged woman with substernal chest pain 4 Adolescent boy with an oxygen saturation of 91% 1 Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin-angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic Clean gloves protect the hands and wrists from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. Masks, sterile gloves, and shoe covers are not required for this situation. Cardiac output Incorrect2 of students nationwide answered this question correctly.49% Confidence: Pretty sure 1130047644 Incorrect3 The nurse is providing information about blood pressure to Unlicensed Assistive Personnel (UAP) and recalls that the factor that has the greatest influence on diastolic blood pressure is: 1 Renal function 3 Oxygen saturation Correct4 Peripheral vascular resistance View Topics Stats Issue with this question? When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? 1 Mask Correct2 Clean gloves Sterile gloves 4 Shoe covers Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the health care provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's The dosage is kept at a minimum. Incorrect1 of students nationwide answered this question correctly.52% Confidence: Nailed it 1140397108 Incorrect1 1 A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? Correct2 Only a small part of the body is irradiated. 3 The client's physical condition is not a risk factor. 4 Nutritional environment of the affected cells is a risk factor. View Topics Stats Issue with this question? Which nursing activities are examples of primary prevention? Select all that apply. Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation A common conflict confronting the older adult is between the desire to be taken care of by others and the desire to be in charge of one's own destiny. The conflict between the young and old age may occur but is not common. The conflict between the retired and working may occur but is not common. The conflict between those wishing to die and those wishing to live may occur but is not common. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve Individuals born after 1957 should receive one additional dose of MMR vaccine if they are students in postsecondary educational institutions. Currently there is no Retirement and work Incorrect2 of students nationwide answered this question correctly.78% Confidence: Pretty sure 1130038720 Diphtheria, tetanus, pertussis (DTaP) Incorrect4 Youth and old age Correct3 Independence and dependence 4 Wishing to die and wishing to live View Topics Stats Issue with this question? A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? 1 Hepatitis C (HepC) 2 Influenza type B (HIB) Correct3 Measles, mumps, rubella (MMR) Understanding the disorder and the details of care are essential for the client to be self- sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no of students nationwide answered this question correctly.49% Confidence: Nailed it 1130035430 Teaching how to make a room allergy-free. Incorrect1 of students nationwide answered this question correctly.79% Confidence: Nailed it 1140389408 C. The HIB immunization is unnecessary. If the student received an additional DTaP at age 12, it is not necessary. A booster dose of tetanus toxoid (Td) should be received every 10 years. View Topics Stats Issue with this question? A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? 2 Referring to a support group for individuals with asthma. 3 Arranging with the college to ensure a speedy return to classes. Correct4 Evaluating whether the necessary lifestyle changes are understood. View Topics Stats Issue with this question? A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish ("DNP") order on any information regarding condition or presence in the hospital. What is the best response by the nurse? "The client has requested that no information be given out. You'll need to call the client directly." The response "We have no record of that client on our unit. Thank you for calling." conforms to the request that no information be given regarding the client's condition or presence in the hospital. HIPAA laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly." implies that the client is admitted to the facility; this violates the client's request that no information should be shared with others. Hospital policies do not prohibit the provision of information to others as long as the client consents. The response "It is against the hospital's policy to provide you with any information regarding any of our clients." also implies that the client is admitted to the facility. "It is against the hospital's policy to provide you with any information regarding any of our clients." Incorrect4 of students nationwide answered this question correctly.51% Confidence: Nailed it 1140402648 Correct2 Correct1 "We have no record of that client on our unit. Thank you for calling." 2 "The new privacy laws prevent me from providing any client information over the phone." 3 View Topics Stats Issue with this question? Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? (Select all that apply.) Correct1 Prayer Hypnosis 3 Medication Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth. Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living of students nationwide answered this question correctly.51% Confidence: Nailed it 1130039666 Achievement of a personal philosophy Incorrect1 of students nationwide answered this question correctly.57% Confidence: Pretty sure 1130036278 Incorrect4 View Topics Stats Issue with this question? What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental task associated with aging? 2 Adaptation to the children leaving home Correct3 Attainment of a sense of worth as a person 4 Adjustment to life in an assisted-living facility View Topics Stats Issue with this question? Which nursing action is confidential and protected from legal action? 1 Providing health teaching regarding family planning. 2 Offering first aid at the scene of an automobile collision. Correct3 Reporting incidents of suspected child abuse to the appropriate authorities. The reporting of possible child abuse is required by law, and the nurse's identity can remain confidential. The nurse is functioning in a professional capacity and therefore can be held accountable. Although the Good Samaritan Act protects health professionals, the nurse is still responsible for acting as any reasonably Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affect an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to of students nationwide answered this question correctly.75% Confidence: Pretty sure 1140351415 Incorrect1 Correct2 Correct4 of students nationwide answered this question correctly.35% Confidence: Nailed it 1130035415 Administering resuscitative measures to an unconscious child pulled from a swimming pool. View Topics Stats Issue with this question? An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.) Difficulty in swallowing Diminished sensation of pain 3 Heightened response to stimuli Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat View Topics Stats Issue with this question? Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth. The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of handwashing before and after Growth Incorrect2 of students nationwide answered this question correctly.49% Confidence: Just a guess 1130047638 Incorrect3 A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust Correct3 Belonging 4 Independence View Topics Stats Issue with this question? A newly hired nurse, during orientation, is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1 "Let me get my preceptor." Correct2 "Wash your hands before and after any client care." "Clean all instruments and work surfaces with an approved disinfectant." 4 "Ensure proper disposal of all items contaminated with blood or body fluids." Saying that everything will be fine provides false hope. Agreeing with the client is an example of offering approval. Commenting on how a client should feel is an example of being judgmental. Implying that the problem is minor is an example of Confidence: Nailed it 1140352612 "Everything will be fine, just wait and see." Correct2 of students nationwide answered this question correctly.75% Confidence: Nailed it 1130045991 Correct1 Stats Issue with this question? A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. The nurse identifies that the UAP is providing false reassurance when the UAP states: 1 "I agree; I think you should get a divorce." 3 "You should be glad that you have such a loving family." 4 "In the scheme of things, you do not have a major problem." View Topics Stats Issue with this question? A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for: Falls 2 Impaired cognition 3 Imbalanced nutrition 4 Impaired gas exchange Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker of students nationwide answered this question correctly.93% Confidence: Nailed it 1130049010 Moves the walker no more than 12 inches in front of the client during use. Correct3 of students nationwide answered this question correctly.74% Confidence: Nailed it 1130037126 Establishing eye contact Correct1 Correct2 The client is at risk for falls related to the leg prosthesis and history of syncope. There is no evidence or contributing factors in the patient scenario of the other View Topics Stats Issue with this question? A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: 1 Picks up the walker and carries it for short distances. 2 Uses the walker only when someone else is present. 4 States that a walker will be purchased on the way home from the hospital. View Topics Stats Issue with this question? What nursing actions best promote communication when obtaining a nursing history? (Select all that apply.) Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not promote communication. Direct questions do not open or promote Using broad, open-ended statements Correct4 of students nationwide answered this question correctly.36% Confidence: Nailed it 1130047653 Correct3 Paraphrasing the client's message 3 Asking "why" and "how" questions 5 Reassuring the client that there is no cause for alarm 6 Asking questions that can be answered with a "yes" or "no" View Topics Stats Issue with this question? A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that the legal term that best describes this situation is: 1 False threats 2 Assault and battery False imprisonment 4 Breach of confidentiality