Nutrition
The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which items from her menu?
A. Nuts and Milk
B. Coffee and tea
C. Cooked rolled oats and fish
D. Oranges and dark green leafy vegetables
Answer: D. Oranges and dark green leafy vegetables.
Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption
Which nurse would be at the highest risk of causing a hazardous situation?
A) A nurse who is administering medications to four clients
B) A nurse who has placed a client in the bed with three side rails up
C) A nurse who is transferred to another unit to assist with care
D) A nurse who has worked 32 hours of overtime this week
D)Health care staff who suffer sleep deprivation due to extended work hours and variable shift assignments are more likely to commit errors and be a factor in adverse events.
What vital signs do you take on a patient?
Select all that apply.
A. TPR
B. Hgb/Hct
C. BP
D. O2
E. H&P
Answer: A. TPR, C. BP, D. O2
VS include: temperature, pulse, respiration, blood pressure, oxygen saturation.
A. open-ended questions
B. Reflective question
C. Closed question
D. validating question
Answer: A. Open-ended question
The nurse's question allows for a wide range of responses and encourages free verbalization, characteristics of a useful open-ended question. Validating questions allow the nurse to confirm what was previously said, while closed questions necessitate a "yes" or "no" answer. A reflective question or comment repeats what the client has recently said.
A. insane clown posse
B. international center of pathology
C. intracranial pressure
D. inductively coupled plasma
Answer: C. intracranial pressure
What are complex carbohydrates? Select all that apply.
A. starch
B. glycogen
C. simple sugars
D. fiber
A. starch
B. glycogen
D. fiber
Complex carbohydrates include: starch, glycogen, and fiber. Dudek pg. 21
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump Which intervention should the nurse implement to ensure electrical safety?
A) Run the electrical cord of the pump under the carpet
B) Tape the electrical cord of the pump to the floor
C) Obtain a three-prong grounded plug adapter
D) Use an extension cord to provide freedom of movement
C) The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the cord under the carpet are not appropriate actions for electrical safety.
How long do you take the apical pulse for?
A. 2 minutes
B. 30 seconds, then times by 2
C. 60 seconds
D. 15 seconds, then times by 4
Answer: C. 60 seconds
A nurse enters a client's room to complete an admission history. The nurse will convey interest in the client's story if the nurse:
A. stands at the foot of the bed and maintains constant eye contact
B. asks all the visitors to leave the room
C. sits at the clients bedside and faces the client
D. hold the medical record while sitting at the bedside and crossing the legs
Answer: C. sits at the clients bedside and faces the client
When possible, sit when communicating with a client. Do not cross the arms or legs because that body language conveys a message of being closed to the clients comments. Constant eye contact may be culturally inappropriate. Visitors may remain in the room is allowed by the client and if they do not obstruct history gathering.
What is the term that means slow heart rate?
A. Brachycardia
B. Bradycardia
C. Hypocardia
D. Tachycardia
Answer: B. bradycardia
What are modifiable risk factors for chronic diseases? Select all that apply.
A. obesity
B. smoking
C. alcohol consumption
D. stroke
E. age
A. obesity
B. Smoking
C. alcohol consumption
Modifiable risk factors include: obesity, smoking, excessive alcohol consumption, and physical inactivity. Dudek pg. 4
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 hand washing? 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 the faucet
E. Allow the hands to air dry after washing
Answer:
B. Wash the hands with soap and water for at least 15 seconds
D. Use a clean paper towel to turn off the faucet
Where can you find the apical pulse?
A. left atrium midclavicular line
B. 5th rib midclavicluar line on the right side
C.2nd intercostal space at the xiphyoid process
D. 5th intercostal space at the midclavicular line
Answer: D. 5th intercostal space at the midclavicular line.
A client is admitted to the emergency room with a diagnosis of acute myocardial infarction. The client tells the nurse, “I’m scared. I think I’m going to die.” Which of the following responses by the nurse would be MOST appropriate?
A. “Everything is going to be fine. We’ll take good care of you.”
B. “I know what you mean. I thought I was having a heart attack once.”
C. “I’ll call your doctor so you can discuss it with him.”
D. “It’s normal to feel frightened. We’re doing everything we can for you.”
Answer: D. “It’s normal to feel frightened. We’re doing everything we can for you.”
What does PERRLA mean?
A. Pupils equal, round, receive light and accord
B. Pupils equal, round, react to light and accommodation.
C. Pupils, eyes, round, reactive, illuminated, accommodating
D. Pupils equivalent, right, round, lively, acclimated.
Answer: B. Pupils equal, round, react to light and accommodation.
The nurse is conducting a dietary assessment on a client who is on a vegan diet.The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?
A. Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin E
Answer: B. Vitamin B12. Vegans do not consume animals products which contain B12.
A registered nurse arrives at work and is told to "float" to the ICU for the day because the ICU is understaffed and needs an additional nurse to care for the clients. The nurse has never worked in the ICU. Which of the following is the most appropriate nursing action?
A. refuse to float in the ICU
B. call the hospital lawyer
C. call the nursing supervisor
D. report to the ICU and identify tasks that can be safely performed
D. report to the ICU and identify tasks that can be safely performed
What places can you assess pulse rate? Select all that apply.
A. posterior tibial
B. brachial
C. radial
D. cranium
Answers: A, B, C
Pulses can be found by: post tib, brachial, radial, ulnar, apical, femoral, popliteal, dorsalis pedis, carotid.
A mother is to undergo a breast biopsy. She tells the nurse, “If lose my breast, I know my husband will no longer find me attractive.” Which of the following responses by the nurse would be MOST appropriate?
A. “You don’t know if you are going to lose your breast. They are just doing the biopsy now.”
B. “You should focus on your children. They are young and they need you.”
C. “You seem to be concerned that your relationship with your husband might change.”
D. “Why don’t you wait and see what your husband’s reaction is before you get upset.”
Answer: C.“You seem to be concerned that your relationship with your husband might change.”
True or False
When you are in abduction, you are moving towards the body, versus when you are in adduction, you are moving away from the body.
False.
Abduction: moving away from the body
Addction: moving towards the body
A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching the client about foods that are allowed should include which food item in a list provided to the client?
A. Tomato soup
B. Boiled shrimp
C. Instant oatmeal
D. Summer squash
Answer: D. Summer squash: Foods that are low in sodium include fruits and vegetables.
A nurse is caring for a client who fell at a nursing home. The client is orientated to person, place, and time and can follow directions. which of the following actions should the nurse take to decrease the risk of another fall? Select all that apply.
A. Place a belt restraint on the client when sitting on the bedside commode
B. Keep the bed in the lowest position with all side rails up
C. Make sure that the clients call light is within reach
D. Provide the client with non-skid footwear
E. Complete a fall risk assessment
Answer:
C. Make sure that the clients call light is within reach
D. Provide the client with non-skid footwear
E. Complete a fall risk assessment
Which of the following values for vital signs would the nurse address first?
A) Heart rate = 72 beats per minute
B) Respiration rate = 28 breaths per minute
C) Blood pressure = 160/86
D) Oxygen saturation by pulse ox= 89%
E) Temperature = 37.2° C (99° F), tympanic
Answer: D. Oxygen saturation by pulse Ox = 89%
ABC's!!!!!
Which therapeutic communication technique is being used in this nurse-client interaction?
Client: "My father spanked me often."
Nurse: "Your father was a harsh disciplinarian."
A. Restatement
B. Offering general leads
C. Focusing
D. Accepting
Answer: A. Restatement
The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the client's statement has been heard and understood.
Questions you would ask upon admission.. Select all that apply.
A. Wt.
B. s/s
C. PRN
D. PMH
E. I&O
Answer: A. weight, B. signs and symptoms, D. past medical history, E. intake and output.