Nursing Process
Which of the following are examples of subjective assessment data? (Select-all-that-apply): A.)"I have 6/10 pain in my belly that is burning and hurts when I move", B.) "I'm scared about my upcoming surgery, I've never been put under before", C.) Blood pressure 116/66, HR 80bpm, RR 18bpm, D.) Wound is red, swollen, 3 cmx5xmx1cm, with sanguineous drainage
What is: A.)"I have 6/10 pain in my belly that is burning and hurts when I move", B.) "I'm scared about my upcoming surgery, I've never been put under before"
What type of isolation do we do for Varicella/Shingles clients? A.) Droplet & Airborne, B.) Contact & Airborne, C.) Droplet & Contact, D.) Neutropenic & Droplet
What is: Contact & Airborne
When is it appropriate to complete vital signs on your client? (Select-all-that-apply): A.) When admitting a client, B.) When there is a change in the client's condition, C.) After the client has been discharged home, D.) Before administering blood
What is: A.) When admitting a client, B.) When there is a change in the client's condition, D.) Before administering blood
This is a possible complication of prolonged immobility/being bedbound for an extended period of time. (Select-all-that-apply): A.) Deep vein thrombus (DVT), B.) Increased strength, C.) Muscle weakness, D.) Foot drop
What is: A.) Deep vein thrombus (DVT), C.) Muscle weakness, D.) Foot drop
Which of the following are examples of open-ended questions? (Select-all-that-apply): A.) "So tell me more about that...", B.) "Can you tell me how you feel about that?", C.) "How many times have you had diarrhea today?", D.) "what are your concerns about this?"
What is: A.) "So tell me more about that...", B.) "Can you tell me how you feel about that?", D.) "what are your concerns about this?"
What type of isolation do we do for CDiff? A.) Airborne, B.) Special contact, C.) Neutropenic, D.) Droplet
What is: B.) Special contact
Which client is at highest risk for tachycardia? A.) A healthy basketball player during warmup exercises, B.) A client admitted with hypothermia, C.) A client with a fever of 39.4 C (103 F), D.) A 90 year-old male client taking beta blockers
What is: C.) A client with a fever of 39.4 C (103 F)
Which of the following are physiological outcomes of immobility? A.) Increased metabolism, B.) Reduced cardiac output, C.) Decreased lung expansion, D.) Decreased oxygen demand
What is: C.) Decreased lung expansion
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A.) The flap closest to the body, B.) The right side flap, C.) The left side flap, D.) The flap farthest from the body
What is: D.) The flap farthest from the body
The nurse observes a client walking down the hall with a shuffling gait. When the client returns to bed, the nurse checks the strength in both of the client's legs. The nurse applies the information gained to suspect that the client has a mobility problem. This conclusion is an example of: A.) Cue, B.) Reflection, C.) Clinical Inference, D.) Probing
What is: C.) Clinical Inference
For a pathogen to be "sensitive" to an antibiotic medication, this means the medication is capable of treating it? A.) True or B.) False
What is: A.) True
A nurse is measuring the BP of a client who has a fractured femur. The BP reading is 140/94 mmHg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A.) Request a prescription for an antihypertensive medication, B.) Ask the client if they are having pain, C.) Request a prescription for an antianxiety medication, D.) Return in 30 min to recheck the client's BP
What is: B.) Ask the client if they are having pain
An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the client has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select-all-that-apply): A.) B/P 128/84, B.) RR 26/min on room air, C.) HR 114 bpm, D.) Crackles over the lower lobes heard upon auscultation, E.) Pain reported as 3/10 after medication given
What is: B.) RR 26/min on room air, C.) HR 114 bpm, D.) Crackles over the lower lobes heard upon auscultation
A clinical instructor is observing a student new care for a client who reports pain. The student nurse checked the client's MAR and noted that the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The student nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The student nurse left out which of the following steps of the nursing process? A.) Assessment, B.) Planning, C.) Implementation, D.) Evaluation
What is: A.) Assessment
A nurse is caring for a 42 year-old mother of 4 who weighs 136.2kg (300 lbs), has Type 2 Diabetes, and works part time in the kitchen of a restaurant. The client is facing gallbladder surgery. Which of the following approaches demonstrations the nurse's cultural competence in assessing the client's healthcare problems? A.) "I can tell that your eating habits have led to your diabetes, is that right?", B.) "It's been difficult for people to find jobs. Is that why you only work part time?", C.) "You have four children; do you have any concerns about going home and caring for them?", D.) "I wish clients understood how overeating affects their health"
What is: C.) "You have four children; do you have any concerns about going home and caring for them?"
Which of the following actions by the nurse comply with core principles of sterile asepsis? (Select-all-that-apply): A.) Set up sterile field before client and other staff come to the operating suite, B.) Keep the sterile field in view at all times, C.) Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated, D.) Only healthcare personnel within the sterile field must wear personal protective equipment, E.) The sterile gown must be put on before the surgical scrub is performed.
What is: B.) Keep the sterile field in view at all times, C.) Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated
The nurse observes a student nurse taking a client's BP. The nurse notes that the student nurse very slowly deflates the cuff in an attempt to hear the sounds. The client's BP range over the past 24 hours is 132/64 to 126/72 mmHg. Which of the following BP readings made by the student nurse is most likely caused by an incorrect technique? A.) 96/40 mmHg, B.) 110/66 mmHg, C.) 130/90 mmHg, D.) 156/82 mmHg.
What is: C.) 130/90 mmHg
To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a client who has had abdominal surgery? A.) Turn, cough, and deep breathe every 30 min while awake, B.) Ambulate client to the chair in the hall, C.) Passive range of motion (ROM) 4 times per day, D.) Immobility is not a concern the first postop day
What is: B.) Ambulate client to the chair in the hall
A nurse is wearing sterile gloves in preparation for a sterile procedure. Which of the following objects can the nurse touch without breathing sterile technique? (Select-all-that-apply): A.) A bottle containing a sterile solution, B.) The edge of the sterile drape at the base of the field, C.) The inner wrapping of an item on the sterile field, D.) An irrigation syringe on the sterile field, E.) One gloves hand with the other gloved hand
What is: C.) The inner wrapping of an item on the sterile field, D.) An irrigation syringe on the sterile field, E.) One gloves hand with the other gloved hand
During a visit to the clinic, a client tells the nurse that he has been experiencing headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? A.) "So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated - correct?", B.) "Have you taken anything for your headaches?", C.) "Tell me what makes your headaches begin"., D.) "Uh huh, tell me more."
What is: C.) "Tell me what makes your headaches begin".
A client has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select-all-that-apply): A.) It allows migration of organisms into the bladder, B.) The insertion procedure is not done under sterile conditions, C.) It obstructs the normal flushing action of urine flow, D.) It keeps an incontinent client's skin dry, E.) The outer surface of the catheter is not considered sterile
What is: A.) It allows migration of organisms into the bladder, C.) It obstructs the normal flushing action of urine flow
A 55 year-old female client was in a motor vehicle accident (MVA) and is admitted to the surgical unit after repair of a fracture L arm and L leg. The also has a laceration on her forehead. She has an IV line infusing in the R antecubital fossa (AC), and pneumatic compression stockings on the R lower leg. She is receiving O2 via a face mask. Which sites do you instruct the nursing assistant to use for obtaining the client's BP and temperature? A.) Right AC and tympanic membrane, B.) Right popliteal and rectal, C.) Left AC and oral, D.) Left Popliteal and temporal artery
What is: A.) Right AC and tympanic membrane
The nurse is caring for a client whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? A.) Cream of broccoli soup with whole wheat crackers, cheese and tapioca for dessert, B.) Hot dog on whole wheat bun with a side salad and apple for dessert, C.) Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert, D.) Turkey salad on toast with tomato and lettuce and honey bun for dessert
What is: A.) Cream of broccoli soup with whole wheat crackers, cheese and tapioca for dessert
A nurse is caring for a client in the Emergency Department (ED) who has an oral body temperature of 38.3 C (101 F), HR 114/min and RR 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select-all-that-apply): A.) Obtain culture specimens before initiating antimicrobials (antibiotics), B.) Restrict the client's oral fluid intake, A.) Obtain culture specimens before initiating antimicrobials (antibiotics), D.) Allow the client to shiver to dispel excess heat, E.) Assist the client with oral hygiene frequently
What is: A.) Obtain culture specimens before initiating antimicrobials (antibiotics), A.) Obtain culture specimens before initiating antimicrobials (antibiotics), E.) Assist the client with oral hygiene frequently