Evolve- Fundamental Skills

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Which activity would the nurse use as an example of fine motor skills of infants aged 2 to 4 months?

Bringing objects from hand to mouth

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what?

Loosen pulmonary secretions

An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client?

Reality orientation

After abdominal surgery a client reports pain. What action should the nurse take first?

Determine the characteristics of the pain

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan?

Accidents, including their prevention

Which statement is true about the nursing model "team nursing"?

Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to?

Explanation

Which theories are most relevant to development in adults? Select all that apply.

Life Span approach Stage-Crisis theory

A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through?

Launching children and moving on

Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee?

Right communication

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?

Calcium

A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse?

"Does it help to joke about your illness?"

What type of functional health pattern would the nurse explain describes values and goals?

Value-belief pattern

A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution?

Place a surgical mask on the client.

How can a nurse best evaluate the effectiveness of communication with a client?

Client feedback

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client?

Reinforcing the client’s strengths and promoting reminiscing

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 what?

Falls

A home health nurse on a first visit checks the client’s vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse’s most appropriate response?

"Of course. I want to do whatever I can for you."

Which developmental changes should be evaluated in girls around 12 years of age?

Skeletal Growth

A nurse is reviewing how a hyperglycemic client’s blood glucose can be lowered. The nurse recalls that the chemical that buffers the client’s excessive acetoacetic acid is what?

Sodium bicarbonate

What principal components are associated with a nurse’s time management skill? Select all that apply.

Goal setting Priority setting Interruption control

On the third postoperative day after 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?

Acknowledge that the client’s withdrawal is an expected and necessary part of initial grieving

Which concept refers to respecting the rights of others?

Open-mindedness

A client is dying. Hesitatingly, his wife says to the nurse, "I’d like to tell him how much I love him, but I don’t want to upset him." Which is the best response by the nurse?

"Why don’t you share your feelings with him while you can?"

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply.

Using pincer grasp well Picking up small objects Showing hand preference

An 80-year-old client 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:

"The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

What are the goals of care when working with families according to the family health system? Select all that apply.

To improve family health or well-being To assist in family management of illness conditions To achieve health outcomes related to the family’s areas of concern

Which intrinsic factor is associated with the fall of an older adult?

De conditioning

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction?

The nurse adjusts the bed and asks if the client is comfortable.

Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply

Dry Cleaners Dye Operators

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what?

Relieve the client’s discomfort

Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client

Arrange these fine-motor skills in ascending order as the infant develops them

Reflexive grasp Looks at and plays with fingers Pulls feet to the mouth Bangs objects together Uses pincer grasp Places objects into containers

Which assessment finding is associated with depression?

The client has islands of intact memory

Which skill in critical thinking requires to be orderly in data collection?

Interpretation

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what?

Promote cell growth and bone union.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what?

Prevent an adult client from getting up at night when there is insufficient staffing on the unit.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client’s room and finds her crying. Which is the most appropriate intervention by the nurse?

Sit down quietly next to the bed and allow her to cry.

A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take?

Inform the client’s healthcare provider.

A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client’s bathrobe. What is the nurse’s initial action?

Tell the client that the cigarettes were found.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcers?

Stage III

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?

Only a small part of the body is irradiated.

A 3-year-old child with eczema of the face and arms has disregarded the nurse’s warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler’s arms to the crib sides, saying, "I’m going to teach you one way or another." How should the nurse’s behavior be interpreted?

These actions can be construed as assault and battery

A client with cancer is informed that the chemotherapy is no longer working and that death is inevitable. Keeping in mind Kübler-Ross’s stages of death and dying, place the following nursing interventions that are most appropriately associated with each stage in order from the stage of denial to acceptance.

1.Avoid confronting the client. 2.Redirect negative feelings constructively. 3.Help the client identify realistic versus unrealistic goals. 4.Help the client celebrate the simple pleasures in everyday life 5.Provide maximal comfort measures.

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer?

The client should have been turned regularly.

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

Impaired neural functioning

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 what?

False Imprisonment

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse’s best intervention?

Attempt to identify the client’s concerns.

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied?

Malpractice

Which therapeutic communication technique is useful when the nurse and a client have a conversation and the client begins to repeat the conversation to himself or herself?

Focusing

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions?

"I should carry objects close to my body."

A nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." How should the nurse respond?

"Your wish will be respected."

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion?

Acknowledging an inability to control the problem

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer’s dementia. The client lives alone. The client’s adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is priority nursing intervention to assist the client with compliance with medication-taking?

Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen.

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client’s room. How should the nurse respond to the technician?

"I can’t receive them right now. Please wait a few minutes or come back."

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents?

Paralytic ileus

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions?

Denial

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions?

"I can’t perform any weightlifting for at least 3 weeks."

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?

Prayer, hypnosis, aromatherapy, guided imagery

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:

Take the temperature

A client diagnosed with tuberculosis is taking isoniazid (INH). To prevent a food and drug interaction, the nurse should advise the client to avoid:

Red wine

A client has been diagnosed with type 1 Diabetes Mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in:

A plastic liquid detergent bottle with a screw-top lid

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client’s medication teaching?

Take the aspirin with meals or a snack, Do not chew enteric-coated tablets, Report persistent abdominal pain

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse’s first consideration when planning care?

Identifying personal feelings toward this client

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

Respiratory and Urinary

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency?

Tachycardia & muscle weakness

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication?

Administer 4 mL of phenytoin suspension containing 125 mg/5 mL

A client’s serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?

Take vital signs and notify the charge nurse or health care provider

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness

A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of the illness. Behaviors that indicate the client is emotionally accepting of impending death are that the client is

Revising the client’s will and planning a visit to a friend

A client with Addison’s disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication?

Tachypnea, hypotension

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment?

Melena, Tachycardia

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the most appropriate initial nursing action?

Offer to spend more time with the client.

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action?

Clients have a right to refuse treatment, nurses are required to answer clients truthfully, the health care provider should have been notified

During history taking, a client reports experiencing black, tarry stools. The nurse recognizes that this may be an indication of

Upper gastrointestinal bleeding

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding?

A separate signed informed consent for routine treatments is unnecessary

A female client explains to the nurse that she sleeps until noon every day and takes frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for a thorough medical evaluation

A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a licensed practical nurse. What group primarily is protected under the regulations of the practice of nursing?

The public

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?

Drinking alcohol daily can cause drug-induced hepatitis

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse’s best response is, "These tests will:

determine adequate dosage levels of the drug

A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention?

Manage pain with oral pain medication

Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion?

Encouraging regular dental checkups, teaching the procedure for breast self-examination

A hospitalized client experiences a fall after climbing over the bed’s side rails. Upon reviewing the client’s medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?

A listing of facts related to the incident as witnessed by the nurse

The nurse assesses a client’s pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is:

Full

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of:

A nutritional deficiency.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client?

Oral temperature 98.2° F, Apical pulse 88 beats per minute and regular, Blood pressure 116/78 mm Hg while in a sitting position

The nurse discovers several palpable elevated masses on a client’s arms. Which term most accurately describes the assessment findings?

Papules

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative?

"A 10-mm-diameter area of drainage at 1900 hours."

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?

Sequence of steps used to meet the client’s needs

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia?

Flushed face, increased pulse rate

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for:

Blood clotting

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client’s lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate:

Arterial Insufficiency

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus?

Teach the client how to exercise the legs.

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for:

Respiratory alkalosis

The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine?

Ketones

The nurse is caring for a client with a closed soft tissue injury. The nurse describes the injury as a/an:

Contusion

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is mostimportant for the nurse to determine if the client is taking because it intensifies the mostserious adverse effect of acetaminophen?

Alcohol

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?

Frequent changes of position

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I’m worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use?

Exploring

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?

Clear breath sounds

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?

Evaluation

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment?

Pain history including location, intensity and quality of pain;Pain pattern including precipitating and alleviating factors

The nurse is preparing discharge instructions for a client that acquired a nosocomial infection, Clostridium difficile. What should the nurse include in the instructions?

The infection causes diarrhea accompanied by flatus and abdominal discomfort

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by:

Lubricating the sigmoid colon and rectum

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure?

Clean the eyelid and eyelashes, apply clean gloves before beginning of procedure, Press on the nasolacrimal duct after instilling the solution

A nurse is preparing to change a client’s dressing. What is the reason for using surgical asepsis during this procedure?

Keeps the area free of microorganisms

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?

Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale

Which statement defines the term family resiliency?

Family resiliency is the ability of the family to cope with stressors.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question?

Parenteral albumin (Albuminar)

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child’s emotional development?

It is where child’s identity and roles are learned

A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client’s plan of care?

Ask the client what is the client’s acceptable level of pain & administer the pain medications regularly around the clock

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?

Friction

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?

The application of force to another person without lawful justification.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client?

Pulmonary edema

The nurse recognizes that what is the reason the faucets on the sinks in a client’s room are considered contaminated?

They are touched by dirty hands when turning the water on.

The nurse recognizes that which are important components of a neurovascular assessment are:

Orientation, Respiratory rate, Pulse and skin temperature

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink:

Cranberry juice

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites?

Decreased liver function

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. A vesicle can be described as:

A lesion filled with serous fluid

A nurse teaches a client about wearing thigh-high anti-embolism elastic stockings. What would be appropriate to include in the instructions?

"You will need to apply them in the morning before you lower your legs from the bed to the floor."

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?

"We have no record of that client on our unit. Thank you for calling."

What are the best ways for a nurse to be protected legally?

Provide care within the parameters of the state’s nurse practice act, document consistently and objectively, Clearly document a client’s non-adherence to the medical regimen

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated?

Pallor, edema, decreased flow rate

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)?

Pain relief, antipyresis, reduced inflammation

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients?

Immediate or potential rehabilitation needs are exhibited by clients with health problems.

What clinical finding indicates to the nurse that a client may have hypokalemia?

Abdominal distention

What is a nurse’s responsibility when administering prescribed opioid analgesics?

Count the client’s respirations, document the intensity of the client’s pain, verify the number of doses in the locked cabinet before administering the prescribed dose

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse?

24 hours

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill?

Personal feelings about terminal illness

What nursing actions best promote communication when obtaining a nursing history?

Establishing eye contact, paraphrasing the client’s message, using broad, open-ended statements

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent?

If the client is allowed to give consent

What should the nurse do initially when obtaining consent for surgery?

Determine whether the client’s knowledge level is sufficient to give consent

What should the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to include foods that result in manageable stools

When assessing a client’s blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands that this finding:

is a normal occurrence

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions?

Standard, airborne, contact

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on the principle that learning:

Requires continued reinforcement

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased blood pressure

When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary?

Medication is irritating to subcutaneous tissue and skin.

Which age-related change should the nurse consider when formulating a plan of care for an older adult?

Increased sensitivity to glare & diminished sensation of pain

Which drug requires the nurse to monitor the client for signs of hyperkalemia?

Spironolactone (Aldactone)

Which nursing activities are examples of primary prevention?

Assisting with immunization programs, facilitating a program about smoking cessation

While receiving a preoperative enema, a client starts to cry and says, "I’m sorry you have to do this messy thing for me." What is the nurse’s best response?

"You seem upset."

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take?

Lower the height of the enema bag

Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply.

Fatigue Morning sickness Breast enlargement

An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client?

Certified nurse midwife (CNM)

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?

Evaluating whether the necessary lifestyle changes are understood

The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, and specifically to avoid the intake of:

Cabbage

A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation?

"Oxygen is exchanged for carbon dioxide in the alveolar membrane.

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?

Inform the health care provider of the inability to afford the medication

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?

"Nontraditional approaches to health care can be beneficial."

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:

Moves the walker no more than 12 inches in front of the client during use

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?

Belonging

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client?

The client will be free of signs and symptoms of infection by discharge

A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link?

Social

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:

Oral temperature of 101.3º F

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as:

Crackles

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond?

"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

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?

"Wash your hands before and after any client care."

The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are:

Less anxious and more aware of reality and therefore ready to learn

In all states of the United States, what is the professional nurse’s legal responsibility regarding child abuse?

Report any suspected abuse to local law enforcement authorities

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that pre-procedure prescriptions will include:

Administering a fleet enema 1 hour before the procedure

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include?

Encouraging daily physical exercise

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client?

It may turn the urine bright yellow.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?

Assess the client’s condition every hour

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson’s conflict of:

Integrity versus despair

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter’s behavior reflect?

Assimilation

Considering Erikson’s developmental theories, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with:

Developing meaningful relationships

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?

"They are done to identify other health risks."

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?

Yogurt

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate when the patient is in the emergency department?

Core rewarming with warm fluids

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage?

Stay nearby without initiating conversation

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

A client who has reached the stage of acceptance in the grieving process appears peaceful, but demonstrates a lack of involvement with the environment. How should the nurse address this behavior?

Accept the behavior the client is exhibiting

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse’s accountability regarding this incident?

Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client

A client is diagnosed with AIDS. When examining the client’s oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection?

Candida albicans

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse’s comment reflect?

Demonstration of a personal bias

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client?

Validation therapy

Which task is most appropriate for a nurse to delegate to unlicensed assistive personnel?

Assessing the blood pressure of a client before physical therapy.

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list?

Heredity

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?

Clean Gloves

When being interviewed for a position as a licensed practical nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response?

False Imprisionment

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?

Cover the wound with a sterile towel moistened with normal saline.

What should a nurse recommend to help a client best during the period immediately after a spouse’s death?

Bereavement counseling

What is a nurse’s most appropriate response, based on current research, when asked about spanking as a disciplinary technique?

"Spanking is strongly suggestive of negative role modeling."

What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client’s skin before obtaining a specimen for a blood culture?

Eliminates surface bacteria that may contaminate the culture

Which intervention reflects the nurse’s approach of "family as a context"?

Trying to meet the client’s comfort

A visitor says to the nurse, "Can I read my client’s progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond?

Do not allow the sponsor to review the record

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?

The child had a right to remain in the room with the other children

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse’s care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse’s initial step in revising the client’s plan of care?

Assess the client’s present status and include the client in a discussion of revisions to the plan of care.

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?

Measles, mumps, rubella (MMR)

A postoperative client says to the nurse, "My neighbor—I mean the person in the next room—sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation?

Move the post-operative client to a room at the end of the hall.

A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?

tubing injection port

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse’s response is: "Let’s go back to what we were just talking about." What therapeutic communication technique did the nurse use?

Focusing

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every four hours. Which diet should the nurse expect the health care provider to prescribe to best meet this client’s immediate nutritional needs?

High in protein and vitamin C

A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation?

Notify the nurse manager about the problem

Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client?

Reinforcing the client’s strengths and promoting reminiscing

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may:

Cause the device to pull away from the skin

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest?

Older adults

Nurses are held responsible for the commission of a tort. The nurse understands that a tort is:

An illegality committed by one person against the property or person of another.

The nurse recognizes that a common conflict experienced by the older adult is the conflict between

Independence and dependence

A nurse receives abnormal results of diagnostic testing. What action should the nurse take first?

Notify the client’s healthcare provider of the results

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client’s spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection:

To the client from outside sources

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on:

The right side

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:

"Everything will be fine, just wait and see."

A nurse is reinforcing teaching to an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? (Select all that apply.)

"What is diabetes? "Can you tell me how the glucose monitor works?"

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:

Peripheral vascular resistance

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply.

Clean the eyelid and eyelashes Apply clean gloves before beginning of procedure Press on the nasolacrimal duct after instilling the solution

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past two weeks. The client states "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client?

"You are worried about paying your bills?"

A nurse is hired to work in a health care facility that has a complete computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says:

"Client information is immediately available when this system is used."

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make?

Meat and milk at the same meal are forbidden.

The nurse is having difficulty understanding a client’s decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client’s behavior illustrate?

Autonomy

A nurse is discussing weight loss with an obese individual with Ménière’s disease. Which suggestion by the nurse is most important?

Keep a diary of all foods eaten each day.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?

Nosocomial

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client?

The plan is formulated and implemented early in the client’s care

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full?

Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage.

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

Bleeding posterior to the nasal packing

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:

4+

A nurse is caring for a client for whom segmental postural drainage treatments are prescribed. The nurse should avoid scheduling the treatment at what time?

After a meal

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?

Arterial blood gas

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy?

"Yes, today is the day that you just mentioned."

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client’s spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction?

To the client from outside sources

A community healthcare nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness?

The children do not have a physical shelter and may sleep outdoors or in vehicles

A nurse is caring for a client diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure?

Surgical asepsis

The home healthcare nurse visits a client who lives with her two grandchildren. The client’s daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form?

Skip-generation family

What should the community nurse teach about the risk of adolescent pregnancy?

Risk for premature birth

The nurse is helping a client and his or her family to set and meet goals with minimal financial cost, time, and energy. Which professional role of the nurse is applicable in this situation?

Caregiver

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply.

Check tubing for kinks Post "no smoking" signs in the clients’ rooms

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. What is it important for the nurse to inform the client of?

That the client must accept full responsibility for possible undesirable outcomes

Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply.

Emotional status Growth and Development

Which description is most appropriate for the family centered care approach?

A collaborative plan of care is developed to achieve optimal health

When caring for a client with venous insufficiency, the nurse would implement which nursing measure?

Elevate the client’s legs above heart level.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?

Provide perineal care.

What is the most important nursing action involved in caring for a client using medications to manage disease?

Administering the medications

A nurse is reviewing a client’s plan of care. What is the determining factor in the revision of the plan?

Effectiveness of the interventions

Which intervention reflects the nurse’s approach of "family as a context"?

Trying to meet the client’s comfort

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education?

"I should monitor weight and food intake once in a month."

Which stage of Piaget’s theory of cognitive development does the nurse observe in a preschooler?

Preoperational

What is the most important skill of the nurse leader?

Clinical care coordination

Which nursing practice is associated with the self-regulation skill?

Reflecting on one’s experience

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

Cover the infected site with a dressing.

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client?

Care that supports homeostatic regulation

Arrange these fine-motor skills in ascending order as the infant develops them.

1. Reflexive grasp 2. Looks at and plays with fingers 3. Pulls feet to the mouth 4. Bangs objects together 5. Uses pincer grasp 6. Places objects into containers

After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococci (VRE), the nurse should take which step to ensure proper disposal of the soiled dressing?

Place the dressing in a red bag/hazardous materials bag

A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in what?

A plastic liquid detergent bottle with a screw-top lid

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 does what?

Moves the walker no more than 12 inches (30.5 cm) in front of the client during use

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission?

Primary nurse

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months?

Transferring objects from hand to hand

Which critical thinking skill does the nurse associate with the concept of maturity?

Ability to reflect on own judgments

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies?

Explanation

Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply.

Dry cleaners Dye workers

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation?

Implementation

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client?

Encourage the client to express feelings

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don an N95 respirator mask before entering the room

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

End-stage renal disease

Which nursing process involves delegation and verbal discussion with the healthcare team?

Implementation

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client?

Contact an interpreter provided by the hospital

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament?

Negative reaction to new stimuli

A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what?

Decrease bacteria in the intestines

An 80-year-old client 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:

"The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution?

0.9% normal saline

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do?

Set priorities and outcomes using the client’s and family input

The nurse is providing interventions to give support services for delivery of care. According to the Nursing Intervention Classification (NIC) taxonomy, which domain does this care belong to?

Health system

Which nursing interventions indicate client care that supports physical functioning? Select all that apply.

Interventions to maintain client’s nutritional status Interventions to maintain client’s regular bowel patterns

A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to do what?

Remove loose rugs from the environment.

After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond?

"I have to go now, but I will come back in 10 minutes."

A nurse is teaching an older client about proper medication use. Which statement made by the client indicates the need for further education?

"I will take over the counter medication along with prescribed medication"

A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client’s plan of care?

Maintain the client in an isolation room

Which suggestion should the nurse offer to parents who are concerned about caring for their toddler?

Encourage the toddler to drink from two-handled cups

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 what?

Oral temperature of 101.3° F (38.5° C)

A nurse is caring for a client whose mobility is restricted to a wheelchair following a motor vehicle accident. The client has been prescribed physiotherapy as a part of rehabilitation care. What interventions should the nurse consider when the client is discharged from the healthcare facility? Select all that apply.

Assist the family in identifying community support systems Encourage the primary caregiver to set a routine time for respite Consider the primary caregiver’s experience in the discharge plan

A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care?

Put the client in a high Fowler position

A nurse is preparing to discharge a client who is partially paralyzed following a stroke. What should the nurse teach the client’s family about recognizing caregiver role strain? Select all that apply.

The caregiver has disturbed sleep patterns. The caregiver has reduced appetite and weight The caregiver is fearful about administering medications to the client

The nurse plans care for a client who has anxiety related to uncertainty over the course of recovery. Which action of the client would indicate that the desired goal is achieved?

The client expresses acceptance of health status by the day of discharge.

A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote what?

Dental Health

The nurse is preparing discharge instructions for a client who acquired a nosocomial Clostridium difficile infection. What should the nurse include in the instructions?

The infection causes diarrhea accompanied by flatus and abdominal discomfort

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what?

Hypokalemia

The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client’s symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to?

Discouraging social interaction to avoid the client’s distraction from outside environment

A client who is human immunodeficiency virus (HIV) positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through what means? Select all that apply.

Blood Semen

The nursing team is providing care for a client. The team leader develops client care plans and coordinates care among the team members. Which member of the team acts as a team leader?

Registered nurse

A client suffering with cancer is at the last stage of life. Which actions should be performed by the nurse to support the client’s family members? Select all that apply.

Helping the family to set up home care Giving the family about the information of dying process Making sure that the family knows about what to do at the time of death

What principle must a nurse consider when caring for a client with a closed wound drainage system?

Fluids flow from an area of higher pressure to one of lower pressure.

A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client’s plan of care include?

Teach family members how to assist with the client’s basic care

While assessing the motor development of an infant, a nurse asks questions to the mother about the infant’s motor skills. Which statement made by the mother indicates that the infant has developed fine-motor skills?

"My child can place objects into containers."

What should the nurse teach the parents about introducing a 6-month-old infant to solid foods?

The infant should be offered one new solid food at a time.

Place each step of the nursing process in the order that it should be used.

1. Obtain client’s nursing history. 2. State client’s nursing needs. 3. Identify goals for care. 4. Develop a plan of care. 5. Implement nursing interventions.

A client asks the nurse, "Should I tell my partner that I just found out I’m human immunodeficiency virus (HIV) positive?" What is the nurse’s most appropriate response?

"You are having difficulty deciding what to say."

While caring for a family, the nurse finds that the family has accepted the shifts of generational roles. Which change in the family status for proceeding developmentally would the nurse observe?

Dealing with retirement

Which nursing actions reflect the carative factor of ‘promoting and expressing positive and negative feelings’ according to the Watson’s transpersonal caring? Select all that apply.

Supporting and accepting the client’s feelings Showing a willingness to take risks in sharing in the relationships when connecting with clients

What is an example of the critical thinking attitude of independent thinking in nursing practice?

To talk with other nurses to share ideas about nursing interventions

The nurse is asking a client with arthritis questions in order to collect information. Which questions asked by the nurse are closed-ended questions? Select all that apply.

"Are you having pain?" "Do you think the medication is helping you to get pain relief?"

The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement?

Chest x- ray

What should a nurse recommend to best help a client during the period immediately after a spouse’s death?

Bereavement counseling

The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context?

Meet the client’s comfort, hygiene and nutritional needs

A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where?

On the hands

A nurse finds that an older adult has reduced consciousness and fatigue and imagines something that is unreal. Which condition does the nurse suspect in the client?

Delirium

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client’s marital and family problems. Which statement by the UAP would the nurse recognize as providing false reassurance?

"Everything will be fine; just wait and see."

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson’s conflict of what?

Integrity versus despair

A mother of a seven-month-old infant reports that her baby still cannot sit without support. Upon asking further questions, the nurse realizes that the child’s gross-motor skills are not properly developed. Which question did the nurse most likely ask the mother?

Can your child hold on to furniture?

An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply

Providing meticulous skin care Reducing shear forces and friction Avoiding pressure with proper positioning

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include?

"Wash your hands before performing the procedure."

When providing preoperative teaching, what should the nurse focus primarily on?

Providing general information to reduce client and family anxiety

Which feature is most likely related to entry-level nurse competencies?

Working as a team member and collaborating with other team members

The nurse is preparing to perform endotracheal suctioning of a client with respiratory difficulties. Before beginning the procedure, what should the nurse do?

Administer 100% oxygen to the client.

The chief operational officer (COO) interviews a nurse and asks, "Tell me about your practical experiences in clinical decision making." Which example would the nurse give?

"I identified impaired skin integrity in a pressure ulcer form upon finding redness in the client’s hip."

The registered nurse is teaching a student nurse about making assumptions with an open mind when looking at information about a client. Which critical thinking skill is being referred to?

Analysis

A nurse finds that his or her surgical mask has become moist before going to a surgery. What should the nurse do?

Dispose of the mask

What safety factor should the nurse teach parents about using a crib for an infant?

Check the slats are less than 6 cm (2.4 in) apart

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention?

Sitting quietly with the client

A client is undergoing radiation therapy. The nurse reassures the client and stays with the client throughout the therapy. Which caring behavior does this nursing action reflect?

Providing presence

While interacting with an older adult, the nurse leans towards the client. What does this posture convey?

The nurse is involved and interested in the interaction.

A client has undergone a subtotal thyroidectomy. The client is being transferred from the postanesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client?

A tracheostomy tray

In which situation does the nurse consider the family as context?

The nurse is caring for an individual with tonsillitis.

The nurse introduces him or herself and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying?

Confidence

Which action by the nurse is appropriate when caring for an elderly client admitted to a healthcare facility?

Invite a family member to join the conversation

Which condition in the client indicates need of nursing care that supports homeostatic regulation? Select all that apply.

Damaged tissue Obstructed airway

Which standards would the nurse explain are important for critical thinking? Select all that apply.

Specific Relavant

The nurse is caring for an older client with arthritis. The client has difficulty standing from and lowering into a chair because of pain. The nurse uses wooden blockers to elevate the chair legs, which helps the client sit and stand with little discomfort. Which critical thinking attitude is involved in this situation?

Creativity

A client complains to the nurse manager about a coworker. The nurse manager listens to both the patient’s and the coworker’s side of the story. Which critical thinking quality is shown in this situation?

Fairness

How can nurses exhibit the concept of open-mindedness as a part of critical thinking behavior in their teams? Select all that apply.

By respecting the right of others to have different opinions By becoming sensitive to the possibility of their own prejudices

A nurse is hired to work in a facility where the nurse assumes responsibility for a number of clients’ needs. What is this nursing care delivery system called?

Primary care nursing

Which question asked by the nurse is an example of open-ended questions?

"How has your health been?"

A client has a platelet count of 49,000/mL (40 × 109/L). The nurse should instruct the client to avoid which activity?

Blowing the nose

The nurse is assessing a client with impaired hearing. Which action of the nurse is most important for establishing a good communication with the client?

Getting the client’s attention

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning?

It requires continued reinforcement.

While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. What would be the rationale behind this?

Ensure adequate exposure to the blood vessels

An older adult with dementia has recently started to make mistakes regarding the time, place, and person. Which action of the nurse would be appropriate in this situation?

Let the client continue to think in his or her own way

The registered nurse teaches a nursing student about the implementation process of nursing. Which example does the registered nurse use while describing indirect care interventions using his or her knowledge?

The management of the client’s environment to prevent infections

The nurse finds that a client prefers Reiki to antidepressants for treating depression. Which intervention of the nurse indicates open-mindedness?

Respecting the client’s preference

A client complains of anxiety before a diagnostic procedure. The nurse explores and collects a thorough assessment to find the reason for client’s anxiety. Which critical thinking attitude is involved in this situation?

Discipline

What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply.

Refrain from smoking around the infant. Refrain from co-sleeping or bed-sharing. Refrain from placing stuffed toys on the infant’s bed.

A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client’s postoperative period?

Turning frequently

The nurse is educating a client about tips for speaking up to help the client to be more involved in his or her treatment. Which statement made by the client indicates the need for further education?

"I should make assumptions regarding the treatment."

While reviewing the performance of a newly appointed nurse, the chief operational officer finds that the nurse excels at using reflective journaling. What activity of the nurse would lead the chief operational officer to this conclusion?

The nurse recalls, thinks, analyzes and learns from day-to-day work situations

A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence?

Reinforce success in tasks accomplished.

According to Kohlberg’s development of moral reasoning, at which phase of life would a child develop premoral orientation?

preschool

Which is an indirect nursing care intervention?

Managing the client’s environment

What should the nurse teach the young mother about the nutritional needs of the newborn?

The newborn should be breastfed for the first twelve months.

Which description relates to Gesell’s theory of development? Select all that apply.

Growth in humans is both cephalocaudal and proximodistal. Growth is maximized only if environmental conditions are adequate. The pattern of maturation follows a fixed developmental sequence in humans.

A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client’s gown?

Pin the prayer cloth to the clean gown

While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse’s conclusion? Select all that apply.

"I have difficulty judging things." "I am unable to do financial calculations." "I am unable to recall words during conversations with my family."

In an interview, the manager is looking for a nurse who excels in analyticity. Which statement made by the nurse would help him or her to get selected for the new project?

"I am good at using evidence-based knowledge."

Which nursing action is a part of the evaluation phase of the critical thinking process? Select all that apply.

Looking at all the situations objectively Using several criteria to determine the effectiveness of a nursing intervention

Which nursing actions reflect Leininger’s caring theory in practice?

The nurse learns culturally specific behaviors to meet the client’s needs

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client?

Imbalanced nutrition: less than body requirements, related to fatigue

The registered nurse is teaching the nursing student about the realms of family life. Which component does the registered nurse include while teaching about integrity processes?

Family rituals

A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention?

Allow the client a longer period of time to complete the meal

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person’s adjustment to the period of senescence will depend largely on adjustment to which developmental stage?

Generativity versus stagnation

A nurse assesses a client’s serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important?

Potassium

A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse’s action?

Accountability

The registered nurse is teaching a nursing student about the skills to build a helping relationship with the client. Arrange the events of the helping relationship in chronological order.

Planning enough time for the initial interaction Assessing the client’s health status Providing information needed to understand and change behavior Achieving a smooth transition for the client to other caregivers as needed

A client who underwent surgery feels pain in the lower abdomen. The nurse provides pain relief but the client is still reporting pain. Which actions of the nurse would help the client to get relief? Select all that apply.

Looking for different distraction techniques Involving the client’s family in creating a new plan for pain relief.

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet?

Asking about what the client knows about the diet that was prescribed

The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate? Select all that apply.

Palpating for tenderness Inspecting any areas of discomfort

When considering Erikson’s psychosocial developmental tasks, a nurse should focus care for middle-aged adults around their need to be:

Productive

The nurse is caring for a client who 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 from what?

Bleeding posterior to the nasal packing

Which nursing actions may help in effective assessment of older clients? Select all that apply.

The nurse makes eye contact with the client. The nurse smiles at the clients during the interaction.

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take?

Start another IV line for the vancomycin and continue the heparin as prescribed.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply.

Dry cerumen Difficulty hearing high-pitched voices

A client is hospitalized for treatment of severe hypertension. Captopril (Capoten) and alprazolam (Xanax) are prescribed. Shortly after admission, the client says, "I don’t think any of you know what you are doing. You are just guessing what I need." What does the nurse determine as the probable cause of this behavior?

Fear of the health problem

A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply.

Tremors Palpitations

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by:

Opening collapsed alveoli and keeping them open.

A client who weighs 176 pounds is to receive 8 mg/kg of cyclosporine (Sandimmune) daily to prevent organ transplant rejection. How many milligrams should the nurse administer each day? Record your answer using a whole number. ___ mg/day

640

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?

High Fowler’s using the bedside table as an arm rest

Which carative factor is involved in creating a healing environment at all levels, physical and non-physical, according to Watson’s Transpersonal Caring?

Providing for a supportive, protective, and/or spiritual environment

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions?

Acceptance

A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a registered professional nurse. What group primarily is protected under the regulations of the practice of nursing?

The public

What is a characteristic of the primary nursing model?

Care is provided by the registered nurse to the client during a stay in a facility.

During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the clinical record. Legally, how should the nurse’s action be interpreted?

The nurse performed her role correctly.

The nurse is assessing a client using the family health system (FHS). Which question should the nurse ask to assess the interactive process of the family?

"Who are the members of your family?"

Which example best demonstrates humility in a critical thinker?

A nurse accepts his or her lack of knowledge regarding stem cell transplantation and seeks opportunities for learning.

A health care provider tells a client about the diagnosis of inoperable cancer and that the client does not have long to live. After the health care provider leaves, the client says to the nurse, "I feel fine. I probably only have the flu." The nurse determines that the client is in the denial stage of grief. What should the nurse do to help meet the client’s emotional needs?

Allow the denial and be available to discuss the situation with the client.

The nurse teaches sterile technique to a family member of a client who is to be discharged with a large abdominal wound that requires a dressing change twice a day. The nurse concludes that further teaching is needed when the family member performs what action during a return demonstration?

Sets the sterile field on the client’s linens at the foot of the bed.

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:

False imprisonment

The most appropriate time for a nurse manager to schedule a 30-minute nursing education class is:

The overlap of each shift.

The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. In doing so, the nurse is aware that in the problem-etiology-signs and symptoms (PES) format:

Nursing interventions are derived from the etiology statement.

A nurse’s coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. How should the nurse respond?

Decline to discuss the friend’s medical condition

A nurse developed and implemented a discharge teaching plan based on the specific needs of a hospitalized client. Which element of decision-making does the primary nurse exhibit in this situation?

Autonomy

The nurse understands that the action of an antidiuretic hormone (ADH) is to do what?

Decrease water loss in urine

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, what should the nurse do?

Remove the sterile drape from its package by lifting it by the corners.

The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant?

Basic personality

The registered nurse is evaluating the statements of a new orienting nurse about wound dressing. Which statement made by the new orienting nurse indicates the need for further teaching?

"I should take the cotton swab placed on the table."

Which nursing interventions require a nurse to wear gloves? Select all that apply.

Cleaning a newborn immediately after delivery Emptying a portable wound drainage system

Which is an example of a nurse-initiated intervention?

Keeping edematous lower extremities elevated on pillows

During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding?

The nurse builds self-esteem by asking about a client’s previous achievements

The nurse is assisting a client in labor. Which intervention should the nurse perform as soon as the newborn is delivered?

Remove nasopharyngeal secretions

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client?

Check the client’s buttocks at least every 2 hours; clean the client immediately after discovering incontinence

A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client’s base of support during the transfer?

Spread the client’s feet away from each other.

Which healthcare factors create barriers that prevent older adults from participating in healthcare promotion and disease prevention? Select all that apply.

Personal motivation Previous healthcare experience

What should the nurse teach the parents of an infant about the use of car seats?

The infant should be restrained properly in a federally approved car safety seat.

Which action of the nurse would be inappropriate in the context of critical thinking skills for making clinical decisions in nursing practice?

The nurse should rely on his or her knowledge and experience when planning and implementing a client care plan.

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have?

7.20

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death?

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death?

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen?

The nurse’s observations were sufficient, and therefore oxygen should have been administered.

A registered nurse advises a nursing student to value learning for learning’s sake. Which concept of critical-thinking behavior is the registered nurse referring to?

Inquisitiveness

Which intrinsic factors may contribute to falls in older adults? Select all that apply.

Deconditioning Impaired vision

A nurse is reviewing the laboratory report of a client with kidney problems. When ammonia is excreted by healthy kidneys, what mechanism usually is maintained?

Acid-base balance of the body

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate?

Core rewarming with warm fluids

A nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun caring for the client. What is the best nursing intervention in preparing for the client’s discharge?

Contact the client’s healthcare provider to discuss use of transdermal medications for pain control.

The nurse is assessing a new mother at a healthcare facility. Which symptom does the nurse identify as a risk factor for postpartum blues?

Mild irritability

The nurse is assessing a young couple planning to start a family. What should the nurse tell the couple about the change that they will have to encounter in their family life-cycle?

Realign relationships with extended family

A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first?

Assess the patency of airway.

Which intervention does the nurse implement to develop a caring relationship with the client’s family?

Identifying the client’s family members and their roles

The home healthcare nurse visits an elderly couple living independently. The wife cares for the husband who has dementia. Which interventions should the nurse implement for them? Select all that apply.

Assess the wife for caregiver burden Assess the husband for signs of physical abuse. Identify social support within the community.

What is the priority nursing intervention for a client during the immediate postoperative period?

Maintaining a patent airway

Which principles are appropriate for promoting older adult learning? Select all that apply.

Use past experiences while teaching Keep the environmental distractions to a minimum Use audio, visual, and tactile cues to enhance learning

A nurse addresses the needs of a client who is hyperventilating to prevent what complication?

Carbonic acid deficit

An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my parent is always angry at me." What is the nurse’s best initial response?

"Your parent is working through acceptance of the situation."

Which subdimension would form a part for the caring process "doing for" according to the Swanson’s theory of caring? Select all that apply.

Protecting Comforting

A nurse is transcribing a practitioner’s orders for a group of clients. Which order should the nurse clarify with the practitioner?

Erythromycin 250 mg TIW

A client has a right-above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don’t remember a thing." What is the nurse’s best response?

"You were in a work-related accident this morning."

The nurse is teaching the parent of an infant about inspecting the crib before putting an infant to sleep. Which statement made by the parent indicates a need for further education?

"I should attach crib toys with hanging strings."

A nurse preceptor is evaluating a nurse who is preparing to administer digoxin intravenously (IV) to a client. The preceptor should stop the nurse from continuing with the procedure when the preceptor observes the nurse doing what?

Piggybacking the digoxin in an existing infusion

A primary healthcare provider tells a client about the diagnosis of inoperable cancer and that the client does not have long to live. After the primary healthcare provider leaves, the client says to the nurse, "I feel fine. I probably only have the flu." The nurse determines that the client is in the denial stage of grief. What should the nurse do to help meet the client’s emotional needs?

Allow the denial and be available to discuss the situation with the client.

Nurses should focus care for middle-aged adults around their need to be what, according to Erikson’s psychosocial developmental tasks?

Productive

The nurse is caring for an infant at the healthcare facility. Which nursing intervention fosters the infant’s development of trust?

Follow the parents’ directions while providing care.

The registered nurse is teaching a nursing student about caring for a client who has difficulty speaking English. Which statement made by the nursing student would cause communication problems with the client?

"I will involve the client’s family members as interpreters."

The registered nurse tells a nursing student, "In the nursing model, the registered nurse is responsible for all aspects of care for one or more clients during a shift of care and the care can be delegated." Which disadvantage would be most likely related to this nursing model?

The continuity of care is a problem

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it where?

On the right side

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention?

Compress the container before closing the port

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition?

Clotting factor deficiency

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer?

Instruct the client to dangle the legs.

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to do what?

Apply suction only as the catheter is being withdrawn

A registered nurse is teaching a nursing student about how to communicate with a client who is cognitively impaired. Which statements made by the nursing student indicate a need for further education? Select all that apply.

"I should use visual cues." "I should speak in a normal tone of voice." "I should face the client so that he or she can see my mouth."

What could be the reason for cataracts in a 36-year-old client? Select all that apply.

Prolonged exposure to heat Prolonged exposure to metal powders

Which statement of the nurse at the time of discharge would reflect the decision-making skill called autonomy?

"I may independently develop and implement a discharge teaching plan."

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client’s outburst, what is the best indication that the nurse-client interaction has been therapeutic?

Relaxation of tensed muscles

The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning?

Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM."

The nurse is assessing a client with an illness. Which questions asked by the nurse indicates that he or she is gathering a client’s physical and developmental health history? Select all that apply.

Do you have any marital problem? Are you able to complete your activities of daily living?

The nurse is assessing a client working in a glass factory. Which occupational hazard should the nurse assess the client for?

Cataracts

A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply

Bringing equipment to the client’s room Transporting the client to a diagnostic test

A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time?

Conducting a multidisciplinary staff conference early during the client’s hospitalization

An isolated older adult is diagnosed with cancer and fears death. Which intervention provided would help to induce relaxation and to communicate interest in the client?

Touch

In the orientation phase, a nurse and a client meet and get to know each other. Which actions should the nurse follow in this phase? Select all that apply.

Prioritizing the client’s problems Clarifying the client’s and nurse’s roles

A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the healthcare provider’s writing. Who should the nurse ask for clarification of this prescription?

Healthcare provider who wrote the prescription

What are the advantages of the team nursing model of providing nursing care? Select all that apply.

The nursing care conferences help to solve client problems. The model provides a high level of autonomy for the team leader The model facilitates a high level of collaboration between team members

The nurse in the emergency department identifies that the admission consent form signed by a critically ill client is not legible. Which statement best reflects the status of this consent?

Consent is legal

Which example in nursing practice would demonstrate Watson’s carative factor called forming a human-altruistic value system?

Using self-disclosure to promote a therapeutic alliance with the client

The registered nurse teaches a nursing student about leadership skills for prioritizing the need of the client depending on the situation. Which statement is an example of an intermediate priority need?

"The measures required to decrease postoperative complications."

The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education?

"I should provide conditional positive support."

After several weeks of caring for clients who are in the terminal stage of illness, the nurse becomes aware of feeling depressed when coming to work. What should the nurse do?

Talk with other nurses on the unit

Which skill would most likely be associated with an effective nurse leader?

Delegating work appropriately

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss?

Making eye contact with the client

A pregnant woman in her second trimester arrives at the local health department, requesting a flu shot. The client states that she gets the flu vaccine every year and has never had an adverse reaction. What action should the nurse perform?

Administer the usual dose of the vaccine

A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction?

"I should obtain a pneumococcal vaccination each year."

To prevent septic shock in the hospitalized client, what should the nurse do?

Use aseptic technique during all invasive procedures

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do?

Increase oral fluid intake to 2 to 3 L/day

During the beginning phase of a therapeutic relationship, why is a clear understanding of participants’ roles important?

The client needs to know what to expect from the relationship.

A 58-year-old client is planning to retire. Which action would be appropriate in this situation?

Assessing issues related to income

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what?

Administering a Fleet enema 1 hour before the procedure

While assessing an older adult, the nurse observes visual impairment in the client. Which technique should the nurse use to communicate?

Encourage the older adult to use assistive devices such as glasses

The professional obligation of a nurse to assume responsibility for actions is referred to as what?

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