Teaching & learning
A nurse is preparing teaching materials for a preschool-aged child. Which teaching method is most appropriate?
A) Detailed lecture
B) Role play and imitation
C) Independent project
D) Question-and-answer session
Answer: B) Role play and imitation
Rationale: Preschool-aged children learn best through interactive and engaging activities such as role play and imitation, which help them understand and retain information through active participation.
A nurse is caring for a client who is experiencing severe shortness of breath and has cyanosis around the lips. Which of the following actions should the nurse take first?
A. Administer oxygen at 2 L/min via nasal cannula.
B. Call the healthcare provider.
C. Administer albuterol via nebulizer.
D. Place the client in high Fowler’s position.
Answer: D.
ABC+D priority: Place the client in high Fowler’s position. Rationale: The first action should be to optimize the client's breathing by positioning them to maximize lung expansion (high Fowler’s position). This is a part of airway management in the ABCs (Airway, Breathing, Circulation) priority framework.
Which communication style may be perceived as "stoic"?
a) Hispanic culture
b) Asian culture
c) German culture
d) British American culture
Answer: b) Asian culture
Rationale: Asian culture is often associated with being reserved and showing little emotion, which aligns with the description provided as "stoic." In many Asian cultures, emotional expression may be more subdued compared to other cultures, emphasizing restraint and composure in communication styles
which abnormality on an EKG is associated w/ hypokalemia?
U wave
A. Equal handgrip strength
B. Negative Trousseau sign
C. Urine output of 100 mL in the last 7 hours
D. Neck vein distention in the supine position.
Answer: C. Urine output of 100 mL in the last 7 hours.
Rationale: Increased urine output indicates the kidneys are functioning to excrete waste and maintain fluid balance, suggesting improvement in hydration status.
Which of the following environments is most conducive to client learning?
A) Dimly lit and quiet
B) Well lit with good ventilation
C) Crowded with multiple distractions
D) Cold and noisy
Answer: B) Well lit with good ventilation
Rationale: A well-lit and well-ventilated environment promotes comfort and focus, enhancing the client's ability to concentrate and absorb information.
A nurse is planning care for a client with severe malnutrition. Which of the following interventions is the highest priority?
A. Encourage participation in a support group.
B. Provide high-calorie, high-protein supplements.
C. Educate the client on balanced nutrition.
D. Monitor daily weight.
Answer: B.
Maslow's Hierarchy of Needs: Provide high-calorie, high-protein supplements. Rationale: According to Maslow's hierarchy, physiological needs (such as nutrition) are the most basic and must be met before higher-level needs. Providing nutritional supplements addresses the immediate physiological need.
Which of the following is a potential barrier to effective communication in the nurse-client relationship?
a) Offering self to the client
b) Giving general leads to encourage the client to elaborate
c) Having consistent communication styles between the nurse and client
d) Preconceived ideas or stereotypical beliefs
Answer: d) Preconceived ideas or stereotypical beliefs
Rationale: Preconceived ideas or stereotypical beliefs can act as barriers to effective communication, leading to misunderstandings or biases in the nurse-client relationship.
How should intravenous potassium be administered to prevent cardiac arrest?
Slowly diluted, not given by IV push
A client with severe vomiting and diarrhea is at risk for which electrolyte imbalance?
A. Hyperkalemia
B. Hyponatremia
C. Hypernatremia
D. Hypocalcemia
When using the teach-back method, what should the nurse do if the client does not accurately restate the information?
A) Move on to the next topic
B) Repeat the information using a different approach
C) Refer the client to written materials
D) Assume the client will understand it later
Answer: B) Repeat the information using a different approach
Rationale: If a client does not accurately restate the information, the nurse should rephrase or use different teaching methods to ensure the client fully understands the material, reinforcing the learning process.
A nurse is caring for a client who reports severe pain 2 days after surgery. What is the nurse's priority action?
A. Administer prescribed analgesics.
B. Assess the characteristics of the pain.
C. Notify the healthcare provider.
D. Apply a warm compress to the site.
Answer: B.
Nursing Process: Assess the characteristics of the pain. Rationale: According to the nursing process, the first step is always assessment. The nurse must gather information about the pain before deciding on an intervention.
What is the primary goal of the orientation phase in the nurse-client relationship?
a) Facilitating communication of distressing thoughts and feelings
b) Assisting clients with problem-solving to help facilitate activities of daily living
c) Establishing trust and rapport
d) Promoting self-care and independence
Answer: c) Establishing trust and rapport
Rationale: The primary goal of the orientation phase in the nurse-client relationship is to establish trust and rapport. During this phase, the nurse and client get to know each other, and the foundation for the therapeutic relationship is laid.
Which body system is most affected by hypermagnesemia?
Neuromuscular system.
A client is admitted with a serum potassium level of 6.8 mEq/L. Which intervention should the nurse implement first?
A. Administering insulin and dextrose
B. Encouraging intake of potassium-rich foods
C. Initiating continuous cardiac monitoring
D. Providing intravenous calcium gluconate
A nurse is educating an older adult client. Which approach is most suitable for enhancing understanding?
A) Use small font and technical jargon
B) Speak quickly to cover all points
C) Use visual aids and primary colors
D) Provide lengthy explanations in one session
Answer: C) Use visual aids and primary colors
Rationale: Older adults benefit from visual aids and primary colors because these elements enhance clarity and comprehension, especially if they have visual impairments or cognitive changes.
A nurse is caring for a client who is restless and attempting to get out of bed without assistance. Which of the following is the least restrictive intervention? A. Apply wrist restraints. B. Use a bed alarm. C. Administer a sedative. D. Ask a family member to sit with the client.
Answer: B.
Least restrictive/least invasive: Use a bed alarm. Rationale: Using a bed alarm is the least restrictive option to ensure the client's safety without physically or chemically restraining them.
Which non-therapeutic communication technique belittles a person's concerns and may cause the client to stop sharing feelings?
a) Falsely reassuring
b) Minimizing feelings
c) Making value judgments
d) Deflecting or changing the subject
Answer: b) Minimizing feelings
Rationale: Minimizing feelings involves downplaying or dismissing a client's emotions, which can hinder therapeutic communication by invalidating the client's experiences.
What is the most common symptom of hypernatremia?
Thirst.
A client with heart failure is prescribed furosemide (Lasix), a loop diuretic. Which electrolyte imbalance should the nurse closely monitor for in this client?
A. Hypocalcemia
B. Hypokalemia
C. Hyponatremia
D. Hypomagnesemia
A nurse is teaching a client with low health literacy. Which strategy is most effective?
A) Use technical medical terms
B) Use easy, common words and large fonts
C) Assume they understand basic health concepts
D) Provide information at the end of the session only
Answer: B) Use easy, common words and large fonts
Rationale: Using easy, common words and large fonts makes the information more accessible and easier to understand for clients with low health literacy, improving comprehension and retention.
A nurse is caring for a client who has a wound infection. Which of the following findings should the nurse report to the provider immediately?
A. Moderate serous drainage from the wound.
B. Client reporting pain at the wound site.
C. Increased erythema and warmth around the wound.
D. Fever of 39°C (102.2°F) and chills.
Answer: D.
Emergent:Fever of 39°C (102.2°F) and chills. Rationale: Fever and chills indicate a systemic infection, which is emergent and requires prompt medical attention.
Which behavior may impact the therapeutic relationship negatively?
a) Consistency in communication and actions
b) Listening attentively to the client's concerns
c) Mutual avoidance and lack of availability
d) Suspending value judgments and maintaining respect
Answer: c) Mutual avoidance and lack of availability
Rationale: Mutual avoidance and unavailability hinder effective communication and can prevent the establishment of a therapeutic relationship between the nurse and client.
What causes fluid to shift from the vascular space into the interstitial space?
Increased capillary hydrostatic pressure.
A 78-year-old patient is admitted for vomiting and diarrhea two days ago. The patient's vital signs are as follows: temperature 38.3°C (100.9°F), pulse 127, blood pressure 100/57, respiratory rate 24, and oxygen saturation 92% on room air. The patient has sinus tachycardia, clear lungs, regular non-labored breathing at rest. An indwelling catheter is in place with 110 mL of amber, concentrated urine output in the last 5 hours. The patient responds to the nurse's question and verbalizes that he is in the hospital and does not feel well. When asked to stick out his tongue, the nurse notes the surface of the tongue has deep furrows, and the mucous membranes are dry and lips are crusty and dry. What are the abnormal assessment findings?
Answer: The abnormal assessment findings include concentrated urine output, tenting of the skin over the sternum, deep furrows on the tongue, dry mucous membranes, and crusty dry lips.
Rationale: Concentrated urine output, tenting of the skin over the sternum, deep furrows on the tongue, dry mucous membranes, and crusty dry lips are all indicative of dehydration. These findings suggest fluid volume deficit (FVD).