cultural diversity
A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply.)
a. Talk to the interpreter about the family while the family is in the room.
b. Determine client understanding several times during the conversation.
c. Look at the interpreter when asking the family questions.
d. Use lay terms if possible.
e. Do not interrupt the interpreter and the family as they talk.
b. Determine client understanding several times during the conversation.
d. Use lay terms if possible.
e. Do not interrupt the interpreter and the family as they talk.
The hospitalized client with limited mobility is at risk for skin breakdown. Which interventions should the nurse include in the plan of care to maintain the client’s skin integrity?
a. Massage vigorously over bony prominences daily
b. Wear sterile gloves when doing skin inspection
c. Apply a moisturizing lotion to body prominences
d. Teach the client to change position every 2 hours
e. Apply an overhead trapeze to the client’s bed
f. Apply barrier cream if stool incontinence occurs
c. Apply a moisturizing lotion to body prominences
d. Teach the client to change position every 2 hours
e. Apply an overhead trapeze to the client’s bed
f. Apply barrier cream if stool incontinence occurs
A 72-year-old client has been in the ICU for the past 2 days. Which intervention would be the most appropriate in decreasing the risk for sensory deprivation? Select all that apply.
a. Remove equipment from the room
b. Explain procedures and routines to the client upon admission
c. Provide a clock and calendar in the client’s room
d. Maintain a balance of activity and rest periods
e. Maintain constant conversation when in the client’s room
c. Provide a clock and calendar in the client’s room
d. Maintain a balance of activity and rest periods
The nurse is evaluating teaching for the client who has DM and is beginning insulin therapy using an insulin pen. Which behavior should best inform the nurse that teaching about insulin administration was effective?
a. The nurse showing the client a video that explains how to use the insulin pen
b. The nurse demonstrating the correct procedure for preparing the insulin pen
c. The client describing the different types of insulins and how to use an insulin pen
d. The client preparing the insulin pen and self-injecting correctly on the first attempt
d. The client preparing the insulin pen and self-injecting correctly on the first attempt
The newly hospitalized 90-year-old client has difficulty answering the nurse’s questions and reports progressive hearing loss. Which nursing action would best aid in communication between the nurse and the client?
a. Overexaggerating facial expressions
b. Using simple sentences
c. Overenunciating longer words
d. Speaking quickly in a higher-pitched voice
b. Using simple sentences
A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?
a. Members of the same religion share similar feelings about their religion.
b. A shared religious background generates mutual regard for one another.
c. The same religious beliefs can influence individuals differently.
d. The nurse and client should discuss the differences and commonalities in their beliefs.
c. The same religious beliefs can influence individuals differently.
A female client can move her right arm and leg but has hemiplegia on the left side. What should the nurse instruct the unlicensed assistant to perform on the client’s left side during care?
a. Active range of motion
b. Passive range of motion
c. Isotonic exercises
d. Isometric exercises
b. Passive range of motion
After conducting a physical assessment, the nurse would conclude that a 75-year-old client’s ability to maintain personal safety would be most adversely affected by declining function in which body system?
a. Cardiovascular
b. Respiratory
c. Sensory
d. Integumentary
c. Sensory
The nurse is preparing for a dressing change using surgical aseptic technique. Which action by the nurse is correct when setting up the sterile field?
a. Dons exam gloves to open the package that contains the sterile drape
b. Uses alcohol to cleanse a solution bottle before placing it on the sterile drape
c. Opens a package of gloves away from the field before donning them
d. Leaves the sterile field unattended to obtain a package of sterile scissors
c. Opens a package of gloves away from the field before donning them
An adult daughter is sitting at the bedside of her mother, a devoutly religious person, who developed a serious postoperative infection. Which statement by the nurse to the daughter demonstrates empathy?
a. “I know how you feel. We also prayed at my grandmother’s bedside when she was sick.”
b. “You’ve been here a long time and look exhausted. Tell me how things are going for you.”
c. “You might as well go home because your mother is sleepy. Maybe tomorrow will go better.”
d. “The new antibiotic was started this morning. We will pray that your mother gets well.”
b. “You’ve been here a long time and look exhausted. Tell me how things are going for you.”
A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?
a. Contact the hospital’s spiritual services.
b. Ask what is making the client cry.
c. Ensure no visitors or staff enter the room for a short time period.
d. Turn on the television for a distraction.
c. Ensure no visitors or staff enter the room for a short time period.
The nurse is evaluating a client using a cane. Which assessment made by the nurse would indicate that the client is using the cane appropriately?
a. Client holds the cane with the hand on the stronger side
b. Client holds the cane with the hand on the affected side
c. Client moves the cane and the affected leg together
d. The cane tip is made of aluminum to prevent slippage
a. Client holds the cane with the hand on the stronger side
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?
a. “I spent my whole life dreaming about retirement, and now I wish I had my job back.”
b. “It’s been so stressful for me to have to depend on my child to help around the house.”
c. “I just heard my friend Al died. That’s the third one in 3 months.”
d. “I keep forgetting which medications I have taken during the day.”
d. “I keep forgetting which medications I have taken during the day.”
The nurse is wearing PPE. Place the steps to removing the PPE in the correct sequence.
a. Remove gown
b. Remove gloves and perform hand hygiene
c. Remove mask
d. Remove eye protection
e. Perform hand hygiene
b. remove gloves and perform hand hygiene
d. remove eye protection
a. remove gown
c. remove mask
e. perform hand hygiene
The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?
a. “Persons entering the room with colds should stay at least 3 feet from me.”
b. “My family plans to bring flowers from my garden to help me feel better.”
c. “The precautions will protect me and help my blood count recover faster.”
d. “Persons entering my room should perform hand hygiene before entering.”
d. “Persons entering my room should perform hand hygiene before entering.”
A nurse is caring for a client who tells the nurse that based on religious values and mandates,
a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?
a. “I believe in this case you should really make an exception and accept the blood transfusion.”
b. “I know your family would approve of your decision to have a blood transfusion.”
c. “Why does your religion mandate that you cannot receive any blood transfusions?”
d. “Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”
d. “Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place,
and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.)
a. Place a belt restraint on the client when they are sitting on the bedside commode.
b. Keep the bed in its lowest position with all side rails up.
c. Make sure that the client’s call light is within reach.
d. Provide the client with nonskid footwear.
e. Complete a fall-risk assessment.
c. Make sure that the client’s call light is within reach.
d. Provide the client with nonskid footwear.
e. Complete a fall-risk assessment.
A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.)
a. Skin thickening
b. Decreased height
c. Increased saliva production
d. Nail thickening
e. Decreased bladder capacity
b. decreased height
d. nail thickening
e. decreased bladder capacity
The clinic nurse is caring for four clients. Which interaction demonstrates the use of the communication technique of reflection?
a. Child: “Don’t turn out the light. I don’t like the dark.”
Nurse: “I will have your mommy hold you while I turn out the light to check your eye.”
b. Adolescent: “My mom won’t let me pierce my tongue.”
Nurse: “What would it be like to have a pierced tongue?”
c. Adult: “My blood sugar was really out of control yesterday.”
Nurse: “Was your blood sugar high or low yesterday?”
d. Older adult: “My life means nothing anymore.”
Nurse: “Socializing more allows you to reflect back on good times and will help you feel better about your life.”
b. Adolescent: “My mom won’t let me pierce my tongue.”
Nurse: “What would it be like to have a pierced tongue?”
The nurse is caring for the postoperative client who is exhibiting signs of delirium. The client is pulling on the IV line, attempting to climb out of bed, and is talking about “the bugs in this hotel.” Which intervention should be the nurse’s priority?
a. Ask the HCP about prescribing haloperidol
b. Transfer the client to a room near the nurse’s station
c. Arrange for the nursing assistant to stay with the client
d. Telephone the client’s family to come and sit with the client
c. Arrange for the nursing assistant to stay with the client
While conducting an initial assessment of an infant, a home health nurse notices that the infant is wearing a soiled piece of braided yarn around the neck. Which action by the nurse is most appropriate?
a. Leave the yarn in place but wash it with a cloth and mild soap
b. Ask about its significance and suggest that it be placed more safely on the body
c. Explain that the yarn offers no benefit and ask the parents to remove it
d. Remove the yarn because it is soiled and could lead to strangulation
b. Ask about its significance and suggest that it be placed more safely on the body
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?
a. Complete a fall-risk assessment.
b. Educate the client and family about fall risks.
c. Eliminate safety hazards from the client’s environment.
d. Make sure the client uses assistive aids in their possession.
a. Complete a fall-risk assessment.
The nurse is caring for the middle-aged client. Which client behavior should indicate to the nurse that the client may have difficulty achieving Erikson's developmental stage of generativity?
a. Talks about accomplishments that made the workplace a better place to work
b. Volunteers at the local nursing home reading to residents 1 day a week
c. Focuses conversation on self and displays disinterest in the activities of others
d. Shows pictures of the client's grandchildren and the client at various sport events
c. Focuses conversation on self and displays disinterest in the activities of others
The nurse makes an error by documenting the wrong VS in the client’s written medical record. Which action would be best to correct the error?
a. Draw a line through the error, initial and date the line, and then document a corrected entry
b. Circle the incorrect entry, write “error” above the entry, and then date and initial the entry
c. Highlight the error in yellow, write the correct VS on the line, and date and initial the line
d. Cover the incorrect VS with the correct VS in such a manner that these are clearly readable
a. Draw a line through the error, initial and date the line, and then document a corrected entry
The clinic nurse encounters the client who has a congested cough and rhinorrhea. The nurse follows droplet precautions/cough protocol by taking which action? Select all that apply.
a. Offering the client sterile disposable tissues
b. Wearing a mask while examining the client
c. Offering the client water to drink while waiting
d. Teaching how to cover the mouth when coughing
e. Performing hand hygiene before and after client contact
f. Separating the client by at least 3 feet from others in the area
b. Wearing a mask while examining the client
d. Teaching how to cover the mouth when coughing
e. Performing hand hygiene before and after client contact
f. Separating the client by at least 3 feet from others in the area