caring/ intervention
A nursing student is reporting to the clinical instructor about the care she gave to a client. She states: "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hr PRN for pain, so I decided he needs it.
I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 min later, and he said his pain is going away." The instructor should inform the student that she left out which of the following steps of the nursing process?
Assessment
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (Select all that apply.)
[]The client's full name
[]The client's date of birth
[]The client's telephone number
[]The dient's diagnosis
[]The dient's room number
[]The client's full name
The client's date of birth
The client's telephone number
A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply)
A. Posture
B. Skin lesions
C. Speech
D. Allergies...
3 domains of learning
Cognitive (Knowledge)
Affective (Attitude)
Psychomotor (Skill)
a newly licensed nurses is talking about their day with another nurse. which statement by the newly licensed nurse demonstrates incivility?
A: i hate when i have to ask my preceptor for help with tasks i am unsure about.
B: the charge nurse called me stupid in front of the team.
C: my preceptor laughs when I tell a joke.
D: the charge nurse give me a difficult assignment
B: the charge nurse called me stupid in front of the team.
During evaluation, the nurse must gather information about the client to
identify whether the client outcomes have been met.
A nurse is assisting with teaching about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include?
a) legitimate absenteeism
b) strict adherence to facility policies
c) consistent adequate work performance
d) frequent reports of not being treated fairly
d) frequent reports of not being treated fairly
A nurse is collecting data for a client's comprehensive physical examination.
After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next?
A. Olfaction
B. Ausculation
C. Palpation
D. Percussion
B. CORRECT: Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next and before using those two techniques
A nurse strives to teach a spouse how to monitor a patient's blood pressure. Which teaching method is best?
1) Provide the patient and spouse with written instruction about how to obtain a blood pressure reading.
2) Demonstrate the technique for taking a blood pressure reading, and then request a return demonstration.
3) Schedule the spouse for a class about high blood pressure, including monitoring technique.
4) Provide the spouse with a patient education brochure about blood pressure monitoring.
2) Demonstrate the technique for taking a blood pressure reading, and then request a return demonstration.
Rationale:
The best way to teach a psychomotor skill, such as obtaining a blood pressure reading, is through demonstration and return demonstration as many learning styles are involved (auditory, visual, kinesthetic). Cognitive learning, which includes storage and recall of information, is most often taught through lecture and print and audiovisual materials.
a nurse is teaching a newly licensed nurse about receiving and transcribing verbal prescriptions. which of the following instructions should the nurse include?
A: read back the prescription to the provider after transcribing.
B: use symbols when transcribing a verbal prescription.
C: include abbreviations when transcribing a verbal prescription.
D: place a zero after a decimal when transcribing a dosage.
A: read back the prescription to the provider after transcribing.
A nursing instructor is reviewing which actions nurses can initiate without a provider's prescription with a group of nursing students. The students should identify which of the following interventions as nurse-initiated? (Select all that apply.)
A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? Select all that apply
a) place the client on round-the-clock surveillance
b) remove the objects from the room that the client could use to arm themselves
c) search items brought into the client's room by visitors
d) refrain from asking the client if they intend to harm themselves
e) screen the client for suicide ideation
a) place the client on round-the-clock surveillance
b) remove the objects from the room that the client could use to arm themselves
c) search items brought into the client's room by visitors
e) screen the client for suicide ideation
A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature?
A. Palmar surface
B. Fingertips
C. Dorsal surface
D. Base of the fingers
C. CORRECT: The dorsal surface of the hand is the most sensitive to
temperature
The patient is given a pamphlet to read about how to manage his newly inserted central venous access device. It will be most important for the nurse to assess the patient's
A. health beliefs.
b. Literacy level.
c. Fine motor abilities.
d. Ability to see
Correct answer: D
If the patient has vision problems, the nurse
will have to find another strategy to convey
the information.
a nurse is caring for a client who asks. "why do i have to talk to so many people before i can go home? don't these people communicate?" which of the following statements should the nurse make?
A: they are very busy and do not have time to communicate about your health.
B: why are you concerned about talking to your health care team?
C: your health care team works together so you can safely go home
D: the sooner you talk with them, the sooner you can leave.
C: your health care team works together so you can safely go home
A nursing instructor is reviewing the steps of the nursing process with a group of nursing students. The students should identify which of the following data as objective? (Select all that apply.)
*Respiratory rate of 22/min with even, unlabored respirations
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
a) record the time and length of the seizure
b) restrain the client's extremities
c) place the client in the prone position
d) monitor the client's hemoglobin level
a) record the time and length of the seizure
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. 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 she is having pain
C. Request a prescription for an antianxiety medication
D. Return in 30 min to recheck the client's blood pressure
B. CORRECT: The first action the nurse should take using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. Therefore, the nurse's priority is to perform a pain assessment. If the client's blood pressure is still elevated after pain interventions, the nurse should report this finding to the provider
Which Domain? Asking a client what he thinks might happen at home and how he might respond
Cognitive
a nurse is preparing a discharge plan for a client following a bilateral below-the-knee amputation. which of the following interventions is the priority?
A: check the availability of transportation to follow-up appointments.
B: request a referral for a home health nurse
C: provide the client with written material about their medications.
D: determine whether the client's home is wheelchair accessible
D: determine whether the client's home is wheelchair accessible
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process?
Reassess the client to determine the reasons for unsatisfactory pain relief.
A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? Select all that apply
a) influenza infection
b) catheter-associated urinary tract infection
c) Mycobacterium tuberculosis infection
d) central line-associated bloodstream infection
e) surgical site infection
b) catheter-associated urinary tract infection
d) central line-associated bloodstream infection
e) surgical site infection
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)
A. Capillary refill less than 3 seconds
B. 1+ pitting edema in both feet
C. Pale nail beds in both hands
D. Thick skin on the soles of the feet
A. CORRECT: The nurse should expect capillary refill in less than 3 seconds as an expected finding
D. CORRECT: The nurse should expect thicker skin on the palms of the hands and the soles of the client's feet
The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? (Select all that apply.)
A. When there are visitors in the room
B. When the patients pain medications are working.
C. Just before lunch when the patient is most awake and alert
D. When the patient is talking about current stressors in his or her life
Answer
B and C
a charge nurse is proving teaching to a group of nurses about the collaborative teamwork skill of situation monitoring. which of the following statements by a nurse indicates an understanding of the teaching?
A: situation monitoring identifies who should be included on the team
B: situation monitoring identifies strategies to lead teams effectively.
C: situation monitoring focuses on the awareness of the team's performance on client outcomes.
D:situation monitoring supports the team by providing feedback to assist the team to function better
C: situation monitoring focuses on the awareness of the team's performance on client outcomes.