nursing process
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
A. Reassess the client to determine the reasons for inadequate pain relief
B. Wait to see whether the pain lessens during the next 24 hours
C. Change the plan of care to provide different pain relief interventions
D. Teach the client about the plan of care for managing the pain
A. Reassess the client to determine the reasons for inadequate pain relief
When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field?
A. Keep the sterile field at least 6 ft away from the client’s bedside.
B. Instruct the client to refrain from coughing and sneezing during the dressing change.
C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound.
D. Keep a box of facial tissues nearby for the client to use during the dressing change.
C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound.
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
A. Prodromal
B. Incubation
C. Convalescence
D. Illness
D. Illness
A nurse is caring for a client who states, “I have to check with my partner and see if they think I am ready to go home.” The nurse replies, “How do you feel about going home today?” Which clarifying technique is the nurse using to enhance communication with the client?
A. Pacing
B. Reflecting
C. Paraphrasing
D. Restating
B. Reflecting
A nurse is preparing information for a change-of-shift report. Which of the following information
should the nurse include in the report?
A. Input and output for the shift
B. Blood pressure from the previous day
C. Bone scan scheduled for today
D. Medication routine from the medication administration record
C. Bone scan scheduled for today
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?
A. Assessment
B. Planning
C. Intervention
D. Evaluation
A. Assessment
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
D. The flap farthest from the body
A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.)
A. Fever
B. Malaise
C. Edema
D. Pain or tenderness
E. Increase in pulse and respiratory rate
A. Fever
B. Malaise
E. Increase in pulse and respiratory rate
Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.)
A. Use an open posture.
B. Write down what the client says to avoid forgetting details.
C. Establish and maintain eye contact.
D. Nod in agreement with the client throughout the conversation.
E. Sit facing the client.
A. Use an open posture.
C. Establish and maintain eye contact.
E. Sit facing the client.
A nurse manager is discussing the HIPAA Privacy
Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.)
A. A single electronic records password is provided for nurses on the same unit.
B. Family members should provide a code prior to receiving client health information.
C. Communication of client information can occur at the nurses’ station.
D. A client can request a copy of their medical record.
E. A nurse can photocopy a client’s medical record for transfer to another facility.
B. Family members should provide a code prior to receiving client health information.
C. Communication of client information can occur at the nurses’ station.
D. A client can request a copy of their medical record.
E. A nurse can photocopy a client’s medical record for transfer to another facility.
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.)
A. Respiratory rate is 22/min with even, unlabored respirations
B. The client's partner states, "They said they hurt after walking about 10 minutes."
C. The client's pain rating is a 3 on a scale of 0 to 10
D. The client's skin is pink, warm, and dry
E. The assistive personnel reports that the client walked with a limp
A. Respiratory rate is 22/min with even, unlabored respirations
D. The client's skin is pink, warm, and dry
E. The assistive personnel reports that the client walked with a limp
A nurse is wearing sterile gloves in preparation
for performing a sterile procedure. Which of the following objects can the nurse touch without breaching 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 gloved hand with the other gloved hand
C. The inner wrapping of an item on the sterile field
D. An irrigation syringe on the sterile field
E. One gloved hand with the other gloved hand
A client has been identified as having a very virulent bacterial infection that is spread through close physical contact. To decrease the chance of spreading this organism, the nurse should implement which infection control precautions?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Protective isolation
C. Contact precautions
A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.)
A. “You will do great! You just have to get used it.”
B. “Why are you worried about going home?”
C. “Your daily routines will be different when you get home.”
D. “Tell me about the support system you’ll have after you leave the hospital.”
E. “It sounds like you are not sure how having a colostomy will affect swimming.”
C. “Your daily routines will be different when you get home.”
D. “Tell me about the support system you’ll have after you leave the hospital.”
E. “It sounds like you are not sure how having a colostomy will affect swimming.”
A charge nurse is reviewing documentation with
a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client’s record? (Select all that apply.)
A. Cover errors with correction fluid, and write in the correct information.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
D. Use as many abbreviations as possible.
E. Wait until the end of the shift to document.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (Select all that apply.)
A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a nasogastric (NG) tube to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to reduce pressure injury risk
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to reduce pressure injury risk
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.)
A. Apply 3 to 5 mL of liquid soap to dry hands.
B. Wash the hands with soap and water for at least 15 seconds.
C. Rinse the hands with hot water.
D. Use a clean paper towel to turn off hand faucets.
E. Allow the hands to air dry after washing.
B. Wash the hands with soap and water for at least 15 seconds.
D. Use a clean paper towel to turn off hand faucets.
The nurse is preparing to change a client's sterile dressing. Which nursing action should the nurse avoid because it would increase the client's risk of developing an infection?
A. Verbally describing to client and family each phase of the dressing change while performing it
B. Checking that sterile dressing packages are intact before opening
C. Opening gauze pads packages before putting on sterile gloves
D. Ensuring that the table that will hold the sterile field is dry
A. Verbally describing to client and family each phase of the dressing change while performing it
Which of the following strategies should a nurse use to establish a helping relationship with a client?
A. Make sure the communication is equally distributed between the nurse’s and client’s desires.
B. Encourage the client to communicate their thoughts and feelings.
C. Give the nurse-client communication no time limits.
D. Allow communication to occur spontaneously throughout the nurse-client relationship.
B. Encourage the client to communicate their thoughts and feelings.
With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.
A. What the client watched on television during the shift
B. What time the nurse will return for the next shift
C. Any abnormal occurrences with the client during the shift
D. Identifying demographics, including diagnosis
E. Current orders
C. Any abnormal occurrences with the client during the shift
D. Identifying demographics, including diagnosis
E. Current orders
A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?
A. “I will determine the most important client problems that we should address.”
B. “I will review the past medical history on the client’s record to get more information.”
C. “I will carry out the new prescriptions from the provider.”
D. “I will ask the client if their nausea has resolved.”
A. “I will determine the most important client problems that we should address.”
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.)
A. The provider drops a sterile instrument onto the near side of the sterile field.
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
C. The procedure is delayed 1 hr because the provider receives an emergency call.
D. The nurse turns to speak to someone who enters through the door behind the nurse.
E. The client’s hand brushes against the outer edge of the sterile field.
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
C. The procedure is delayed 1 hr because the provider receives an emergency call.
D. The nurse turns to speak to someone who enters through the door behind the nurse.
Several clients are being admitted to the hospital unit at one time. There is only one private room available. Which client has the highest priority for being admitted to this private room?
A. A client admitted for elective surgery who requested a private room prior to admission
B. A client who has a large infected abdominal wound
C. A client who has a communicable airborne infection
D. A client who is under the age of 12
C. A client who has a communicable airborne infection
A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take?
A. Touch the child's arm
B. Sit at eye level with the child
C. Stand facing the child
D. Stand with a relaxed posture
B. Sit at eye level with the child
In SBAR, what does R stand for?
A. Reinforcing data
B. Response
C. Recommendations
D. Report
C. Recommendations