Fundamentals
med/surg
peds
OB
Mental Health
100
Identify which of the following nursing actions is an internal factor • Ensuring privacy with your patient • Preventing disruptions by posting a sign on • Listening to your patient and paying attention to their nonverbal cues. • Turning off TV to omit distractions
What is Listening to a patient and paying attention to their non-verbal cues
100
A patient comes into the hospital with a sudden, life-threatening onset of pulmonary distress. What kind of data collection would you use to get a health history? • Follow up Database • Complete • Focused/problem-centered • Emergency
What is Emergency
100
A nurse is providing home care instructions to the mother of a 10-year-old with hemophilia. Which of the following activities should the nurse suggest that the child could participate in safely with peers? soccer basketball swimming field hockey
What is swimming
100
24. The postpartum nurse is providing instructions toa client of a health newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? a. 3 days postpartum b. 7 days postpartum c. On the day of birth d. Within two weeks postpartum
What is 3 days postpartum A
100
7. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? a. Ask the client why he started taking illegal drugs? b. Ask the client about the amount of drug use and its effect c. Ask the client how long he thought that he could take drugs without someone finding out d. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home
What is ask the client about the amount of drug use and its effect B
200
Which of the following is an example of an appropriately written assessment intervention? a. Patient will ambulate down the hall 2x daily b. The patient was able to ambulate down the hall 2x daily c. Administer pain medications regularly and assess patient's pain d. The patient's pain is 7/10
What is Administer pain medications regularly and assess patient's pain C
200
A patient's pulse is 48 beats per minute. Which of the following patients would you identify this as unexpected? • 18 year old high school soccer player • 32 y/o man who is sleeping • 50 year old man taking anti-anxiety medication • 44 year old women who has just eaten breakfast.
What is 44 year old women who has just eaten breakfast
200
A nurse is monitoring a child with burns during treatment for burn shock. The nurse understands that which of the following assessments provides the most accurate guide to determining the adequacy of fluid resuscitation? skin turgor neurological assessment level of edema at burn site quality of peripheral pulses
What is neurological assessment since the burn itself does not affect this, it would be a good indicator of adequate fluid levels
200
25. The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? a. Elevate the clients legs b. Massage the fundus until it is firm. c. As the client to turn on her left side d. Push on the uterus to assist in expressing clots
What is massage the fundus until it is firm B
200
9. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2 bed room. A newly admitted client will be assigned to this clients room. Which client would be the best choice as a roommate for the client with anorexia nervosa? a. A client with pneumonia b. A client undergoing diagnostic tests c. A client who thrives on managing others d. A client who could benefit from the client's assistance at meal times
What is A client undergoing diagnostic testing
300
a nurse is preparing to remove and NG tube. The nurse should instruct the client to do which of the following just before the nurse removes the tube? exhale inhale and exhale quickly take and hold a deep breath perform a Valsalva maneuver
What is Take and hold a deep breath this will close the epiglottis and allow for easy removal
300
6. A 16 year old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development post operatively? a. Encourage the client to rest and read. b. Encourage the parents to room in with the client. c. Allow the family to bring in the clients favorite computer games. d. Allow the client to interact with others in the same age group
What is allow the client to interact with others in the same age group. D
300
26. When performing a postpartum assessment on a client, the nurse notes the presence of clots and notes that they are larger than 1cm. which nursing action is most appropriate? a. Document the findings b. Reassess the client in 2 hours c. Notify the health care provider d. Encourage increased fluid intake
What is notify the health care provider C
300
10. The nurse is conducting an initial assessment of a client in crisis. When assessing the clients perceptions of the precipitating event that lead to the crisis, which is the most appropriate question? a. “whith whom do you live?” b. “who is available to help you?” c. “what leads you to seek help now?” d. “What do you usually do to feel better?”
What is what leads you to seek help now C
400
the nurse is assisting a doctor with the removal of a chest tube. The nurse should instruct the client to: exhale slowly stay very still inhale and exhale quickly perform the Valsalva maneuver
What is perform the Valsalva maneuver an alternative instruction is to take a deep breath and hold it
400
You are going into surgery and your nurse says, "I'm sure you're going to be fine!" What type of interviewing trap is this? a. Giving unwanted advice b. Leading or biased question c. Providing false assurance d. Talking too much
What is providing false reassurance C
400
7. A mother arrives at the clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? a. Allow the child to set bed time limits b. Allow the child to have temper tantrums c. Avoid letting the child nap during the day d. Inform the child of bedtime a few minutes before it is time for bed.
What is inform the child of bedtime a few minutes before it is time for bed D
400
28. The nurse is preparing to care for four assigns clients. Which client is at most risk for hemorrhage? a. A primiparous client who delivered 4 hours ago b. A multiparous client who delivered 6 hours ago c. A multiparous client who delivered a large baby after oxytocin induction d. A primiparous client who delivered 6 hours ago and had epidural anesthesia
What is a multiparous client who delivered a large baby after oxytocin induction C
400
11. A depressed client on an inpatient unit says to the nurse, “My family would be better off without me.” Which is the nurses best response? a. “Have you talked to your family about this?” b. “Everyone feels this way when they are depressed.” c. “You will feel better once your medication begins to work.” d. “You sound very upset. Are you thinking of hurting yourself?”
What is You sound very upset. Are you thinking about hurting yourself? D
500
What are the 3 parts of the nursing diagnosis? a. Temperature, Pulse, respirations b. Problem, etiology, symptoms c. Medical diagnosis, defining characteristics, health perception d. Medical diagnosis, MAR, potential risks
What is problem, etiology, symptoms B
500
The nurse is reviewing the lab results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? increase calcium increased WBC decreased BUN decreased number of plasma cells in bone marrow
What is increased calcium the nurse can expect increased plasma cells in bone marrow, anemia, hypercalcei=mia, and elevated BUN
500
8. The clinic nurse instructs the patents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? a. Stress b. Trauma c. Infection d. Fluid overload
What is fluid overload D
500
A postpartum client is diagnosed with cystitis. the nurse plans for which priority nursing intervention? providing sitz baths encouraging fluid intake placing ice on the perineum monitoring hemoglobin and hematocrit levels
What is encourage fluid intake this is an infection of the bladder so fluid intake will help to flush out
500
12. The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? a. Administer antianxiety medication b. Assess and treat the wound sites c. Secure and record a detailed history d. Encourage and assist the client to ventilate feelings.
What is assess and treat the wound sites B
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