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Terms in this set (105)A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? a. A client who has a history of physical
abuse d A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should
the nurse make? c A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when
assessing the quality of the client's pain? d A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? a. Insert the IV catheter into the back of
the client's hand. c A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement? a. The tube aspirate has a pH
of 7. b A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. Activate the emergency fire alarm. c A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? a. Carry a client's soiled linens out of the room in a mesh linen bag. b A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legally witness? (Select all that apply.) a. A teacher who brings in a 7-year-old
student bcde A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? a. Document the provider's statement in the medical record. b. A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. a A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet? a. Beef liver d A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? a. the client is receiving formula at room temp d A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? b A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein? d A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device? a. "This type of hearing aid does not allow for fine tuning of volume." d A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? a. Talk directly to the client, instead of the interpreter, when speaking. a A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a. Administer the medication with the needle at a 45° angle. a A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope? a. Second intercostal space at the left sternal border a A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "When descending stairs, I will first shift my weight to my right leg." a A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? a. Numbness of the extremities D a pt with hyponatremia (low sodium level) will have what? abdominal cramping, weakness, headache and nausea Where should a nurse listen for a pt with a heart murmur second intercostal space at the left sternal border and apex
A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? a. "We will determine who the durable power of attorney for health care form has designated." b A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a. Increase in hematocrit c A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field? a. The nurse opens the sterile field on a wet surface. a A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? a. Uniform pigmentation c A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? a. During the admission process a A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? a. Thread the IV catheter so that the hub rests at the insertion site. a A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? a. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. b A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? a. "Most people are happy when their children grow up and leave home." d A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. Make sure the client's room has at least 6 air exchanges per hour. b A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
a. Role play d A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) a. Assist the client with a partial bed bath. a b d A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? a. Pad
the client's wrist before applying the restraints. a A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next? a. Clean sutures along the incision site.. a A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? a. Examine personal values about the issue. A A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? a. "I think I should take my pain medication more often, since it is not controlling my pain." c A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse? a. Loss of skin turgor on the back of the hands d A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? Contact b _________ precautions are a requirement for clients who have infections that spread via direct ________ with clients or from environmental ________. Examples are vancomycin-resistant enterococci and herpes simplex infections. contact ___________ precautions are a requirement for clients who have infections that spread via _________ nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 ft) of the client who has a disorder requiring this precaution. Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Airborne Clients who have an immune system compromise, such as those who have had an allogeneic stem cell transplant, require a _____________ environment. It keeps them from acquiring infections from others. protective A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter? a. Small air bubbles are in the IV tubing. c A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup c A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? a. Insert the suction catheter while the client is swallowing. b A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation? a. Urine has an unusual odor. c A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? a. Admitting diagnosis b A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? a. Rock the client up to a standing position. c A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.) a. Check the cord routinely for frays or tearing. a c d A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
a. Reduce dietary sodium. c A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. Press gently on the tragus of the client's ear. a A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? a. A nurse tied a client's restraint straps to the moveable part of the bed frame. d A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. Discuss the risk factors
for colon cancer. d A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? a. Dissolve each medication in 5 mL of sterile water. d A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? a. Bend at the waist. d A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a. "I'm having mild
pain." b A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. BUN 15 mg/dL d A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? a. The top of the cane is parallel to the client's waist. c A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. Assign the client to a room with a negative air-flow system. d A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? a. Ask another nurse to observe the medication wastage. a A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? a. Place the client in a side-lying position. c A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) a. Lacrimal apparatus b d e A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? a. Purulent exudate c A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. Gently shake the container of medication prior to administration. a A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? a. Auscultate lung sounds. a A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? a. Tell the client which food she should eat
first. d A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? a. Erythema on pressure points a A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. Use a resuscitation bag with 80% oxygen prior to the procedure. b A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? a. Airborne a A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? a. Drink a cup of hot cocoa before bedtime. c A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? a. Check the client for injuries. a A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? a. "When do you usually bathe, in the morning or in the evening?" d A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? a. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." c A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. Rinse the feeding bag with water between feedings. b A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? a. Touch the face with a cotton ball. c A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? a. "I'll get a blood sample from you and send it for a screening test." c A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention c A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? a. Neck vein distention c A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? a. Allow extra time for the client to respond to questions. a A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? a. Protective environment d A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? a. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse. b A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. Wear sterile gloves when removing the old dressing. c A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. a. inject 5 units of air into the bottle of regular insulin c a d b A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine." c A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a. Insert an implanted port. d A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? a. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. d A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a. Place the client in high-Fowler's position. d A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? a. Request that a respiratory therapist discuss the technique for incentive
spirometry. b A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? a. Insert the catheter at a
45° angle. b A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? a. "Use the complete name of the medication
magnesium sulfate." a A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question?
a. The medication c A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? a. Apply the stockings so the creases are on the front side of the leg. c A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress? a. Role ambiguity c A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a. position the chair
on the left side of the bed b a c d A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? a. Critical pathway b A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I can concentrate best in the morning." a A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? a. Biofeedback d A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? a. Suction the client's airway. d A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a. "What could I have done to deserve this illness?" a A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. Ensure sterilization of nondisposable items with ethylene oxide. b A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) a. Place the client in a room with negative-pressure airflow. a b e A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. Walking briskly a A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? a. "They allow the court to overrule an adult client's refusal of medical treatment." b A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation? a. "We are not worried. We still have hope that everything will be okay." b Sets with similar termsFundamentals Practice Test A60 terms countesso Fundamentals NCLEX questions52 terms lacy6676 ATI Quiz: Fundamentals 140 terms shaaleese Sets found in the same folderATI Fundamentals68 terms VyNguyen1148 RN Funds Practice 2019 A60 terms mhuerta77PLUS ATI Fundamentals - Practice A60 terms sarahpayne99PLUS ati proctored fundamentals198 terms Kia_Taylor45 Other sets by this creatormark klimek (Overview)237 terms ftrnrs21 Pharmacology NCLEX372 terms ftrnrs21 Pharm2377 terms ftrnrs21 ATI RN Predictor Study 2019- Me334 terms ftrnrs21 Other Quizlet setsDrugs for Diabetes Mellitus31 terms jessieevargas 02_Viren und Virale Pathogenese29 terms adii_98PLUS Pharmacology - Chapter 119 terms Atillar Anthro 315 Iowa State Hill Exam 265 terms Trenton516 What are 3 coping strategies for stress?Healthy Ways to Cope with Stress. Take breaks from watching, reading, or listening to news stories, including those on social media. ... . Take care of yourself. ... . Take care of your body. ... . Make time to unwind. ... . Talk to others. ... . Connect with your community- or faith-based organizations.. Avoid drugs and alcohol.. Is there a best strategy to respond to a stressful situation?Commit to a Positive Attitude. A positive attitude helps stop you from being dragged down by unhappy feelings. A positive attitude also boosts the problem solving that a stressful situation requires. A positive attitude helps us see the possibilities within a situation, while negative thinking narrows our view.
How do you deal with a high stress situation?Forget the reason you feel stressed in the first place — you are being asked to do something important and you want to succeed.. Let the negative voice in your head spiral out of control — talk to yourself in a logical, gentle tone.. Project your stress onto others — speak in a calm, controlled way and others will too.. How do you handle stress and pressure?Taking steps to manage stress. Track your stressors. Keep a journal for a week or two to identify which situations create the most stress and how you respond to them. ... . Develop healthy responses. ... . Establish boundaries. ... . Take time to recharge. ... . Learn how to relax. ... . Talk to your supervisor. ... . Get some support.. |