Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

Nursing Interventions, Client Teaching, and Ethical Principles, Exams of Nursing

A collection of questions and answers related to nursing interventions, client teaching, and ethical principles. It covers various topics such as medication administration, home safety, pressure ulcer prevention, and end-of-life care. The answers also include rationale and references to ati pn comprehensive predictor form a,b,c questions and answers latest 2023-2024 test bank.

Typology: Exams

2023/2024

Available from 04/02/2024

nursinghero
nursinghero 🇬🇧

2

(4)

639 documents

1 / 24

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
ATI PN COMPREHENSIVE PREDICTOR FORM A,B,C
QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK
100 % COMPLETE
. If a client develops cor pulmonale (right-sided heart failure), the nurse
would expect to observe
1. increasing respiratory difficulty seen with exertion.
2. cough productive of a large amount of thick, yellow mucus.
3. peripheral edema and anorexia.
4. twitching of extremities. - ans3
. The nursing team includes two RNs, one LPN/LVN, and one nursing
assistant. The nurse should consider the assignments appropriate if the
nursing assistant is assigned to care for
1. a client with Alzheimer's requiring assistance with feeding.
2. a client with osteoporosis complaining of burning on urination.
3. a client with scleroderma receiving a tube feeding.
4. a client with cancer who has Cheyne-Stokes respirations. - ans1
A 23-year-old man is admitted with a subdural hematoma and cerebral
edema after a motorcycle accident. Which of the following symptoms should
the nurse expect to see INITIALLY?
1. Unequal and dilated pupils.
2. Decerebrate posturing.
3. Grand mal seizures.
4. Decreased level of consciousness. - ans4
A 23-year-old woman at 32-weeks gestation is seen in the outpatient
clinic. Which of the following findings, if assessed by the nurse, would
indicate a possible complication?
1. The client's urine test is positive for glucose and acetone.
2. The client has 1+ pedal edema in both feet at the end of the day.
3. The client complains of an increase in vaginal discharge.
4. The client says she feels pressure against her diaphragm when the baby moves. - ans1
A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if
found by the nurse at the patient's bedside, is nonessential?
1. Potassium chloride for IV administration.
2. Calcium gluconate for IV administration.
3. Tracheostomy set-up.
4. Suction equipment. - ans1
A 59-year-old woman with bipolar disorder is receiving haloperidol
(Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my
breasts." Which of the following responses by the nurse is BEST?
1. "You are seeing things that aren't real."
2. "Why don't we go make some fudge."
3. "You are experiencing a side effect of Haldol."
4. "I'll contact your physician to change your medication." - ans3
A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse?
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
pff
pf12
pf13
pf14
pf15
pf16
pf17
pf18

Partial preview of the text

Download Nursing Interventions, Client Teaching, and Ethical Principles and more Exams Nursing in PDF only on Docsity!

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

. If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe

  1. increasing respiratory difficulty seen with exertion.
  2. cough productive of a large amount of thick, yellow mucus.
  3. peripheral edema and anorexia.
  4. twitching of extremities. - ans . The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for
  5. a client with Alzheimer's requiring assistance with feeding.
  6. a client with osteoporosis complaining of burning on urination.
  7. a client with scleroderma receiving a tube feeding.
  8. a client with cancer who has Cheyne-Stokes respirations. - ans A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY?
  9. Unequal and dilated pupils.
  10. Decerebrate posturing.
  11. Grand mal seizures.
  12. Decreased level of consciousness. - ans A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
  13. The client's urine test is positive for glucose and acetone.
  14. The client has 1+ pedal edema in both feet at the end of the day.
  15. The client complains of an increase in vaginal discharge.
  16. The client says she feels pressure against her diaphragm when the baby moves. - ans A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential?
  17. Potassium chloride for IV administration.
  18. Calcium gluconate for IV administration.
  19. Tracheostomy set-up.
  20. Suction equipment. - ans A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST?
  21. "You are seeing things that aren't real."
  22. "Why don't we go make some fudge."
  23. "You are experiencing a side effect of Haldol."
  24. "I'll contact your physician to change your medication." - ans A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse?

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

  1. The client complains of pain during the inflow of the dialysate.
  2. The client complains of constipation.
  3. The dialysate outflow is cloudy.
  4. There is blood-tinged fluid around the intra-abdominal catheter. - ans A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting - ansD A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?
  5. Administer PRN haloperidol (Haldol) to decrease the need to walk.
  6. Assess the client's gait for steadiness.
  7. Restrain the client in a geriatric chair.
  8. Administer PRN lorazepam (Ativan) to provide sedation. - ans A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet?
  9. Protein.
  10. Fats.
  11. Carbohydrates.
  12. Magnesium. - ans a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider - ansserum potassium 5. a client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medication - ansthrombocytes, amylase count and liver function test A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant - ansD A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to
  13. take the medication five minutes after the pain has started.
  14. stop taking the medication if a stinging sensation is absent.
  15. take the medication on an empty stomach.
  16. avoid abrupt changes in posture. - ans

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

  1. Increase the intake of high-carbohydrate foods.
  2. Avoid eating large meals that are high in simple sugars and liquids. - ans A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
  3. confused with cold, clammy skin and a pulse of 110.
  4. lethargic with hot, dry skin and rapid, deep respirations.
  5. alert and cooperative with a BP of 130/80 and respirations of 12.
  6. short of breath, with distended neck veins and a bounding pulse of 96. - ans A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure?
  7. Positive Babinski.
  8. High-pitched cry.
  9. Bulging posterior fontanelle.
  10. Pinpoint pupils. - ans A nonstress test is scheduled for a client at 34-weeks gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test?
  11. Start an intravenous line for an oxytocin infusion.
  12. Obtain a signed consent prior to the procedure.
  13. Instruct client to push a button when she feels fetal movement.
  14. Attach a spiral electrode to the fetal head. - ans A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea - ansA A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days?
  15. The patient eats most of the food served to her.
  16. The patient has gained 1 pound since admission.
  17. The patient's albumin level is 4.0mg/dL.
  18. The patient's hemoglobin is 8.5g/dL. - ans

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self-care tasks d) ask the client if a family member is available to assist with his care - ansC A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter - ansA A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. Nonmalificience - ansA A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the wound - ansC A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chloride - ansC A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room - ansA

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning - ansB C D A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside - ansA A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - ansC a nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin). which of the following over the counter medication should the nurse instruct the client to avoid - ansAspirin A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances - ansB C E a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV). for what adverse effect should the nurse monitor this client - ansthe nurse should monitor the client respiratory depression A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.)

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home. - ansB C E A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. ____ Passive smoking ____ Carbon monoxide poisoning ____ Food poisoning A. Have water heaters inspected on an annual basis. B. Cook all meat at an appropriate temperature. C. Avoid enclosed areas with others who may be smoking. - ansC A B A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale c) black coffee d) orange sherbet - ansD a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching - ansi should decrease the amount of calcium in my diet while taking the medication A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step - ansC a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teaching - ansI will tell my doctor before I stop taking the medication a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include - ans1. change position slowly to minimize dizziness

  1. chewing sugarless gum to prevent dry mouth

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake - ansC A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of - anscalcium gluconate (because hypocalcemia causes Chvostek's sign) A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?

  1. "I keep having recurring nightmares."
  2. "I have a headache and my stomach has bothered me for a week."
  3. "I always check the door locks three times before I leave home."
  4. "I don't know who I am and I don't know where I live." - ans Adverse effect of Verapamil - ansAvoid grapefruit juice Adverse effects of ferrous sulfate - ansconstipation; upset stomach; black or dark-colored stools; or. temporary staining of the teeth. After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan?
  5. Alteration in mobility related to paralysis.
  6. Alteration in skin integrity related to decrease in tissue oxygenation.
  7. Alteration in skin integrity related to immobility.
  8. Alteration in communication related to decrease in thought processes - ans After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
  9. Irrigate the nasogastric tube with distilled water.
  10. Aspirate the gastric contents with a syringe.
  11. Administer an antiemetic medicine.
  12. Insert a new nasogastric tube. - ans After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?
  13. The client has slight edema of the eyelids.
  14. There is clear fluid draining from the client's right ear.
  15. There is some bleeding from the child's lacerations.
  16. The client withdraws in response to painful stimuli. - ans

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver - ansC Alcohol Use Manifestations of Withdrawal - ansBody burns 0.5 oz of alcohol per hour

  • Withdrawal appears within 4-12 hours
  • Irritability + Tremors + Anxiety
  • Nausea + Vomiting + HA
  • Diaphoresis
  • Sleep Disturbances
  • TACHYCARDIA + HTN Use Benzodiazepines = tx Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) alcohol withdrawal heroin withdrawal nicotine withdrawal alcohol abstinence opioid over dose - anschlordiazeproxide( Librium) methadone( dolophine) bupropion ( wellbutrin) disulfiram ( antabuse) naloxone (narcan) An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
  1. in semi-Fowler's position.
  2. prone, with the head turned to the side.
  3. with the head of the bed elevated 45° and the neck extended.
  4. supine, with the head in the midline position. - ans An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse?
  5. "Take the medication on a full stomach, or with a glass of milk."
  6. "Wear sunscreen and a hat when outdoors."
  7. "Continue taking the medication until you feel better."
  8. "Avoid the use of soaps or detergents for two weeks." - ans An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client
  9. eat a high-protein, low-residue diet.
  10. lie on her unoperated side.
  11. exercise her arms and legs.

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply.

  1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.
  2. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.
  3. Promote relaxation before bedtime with a warm bath or relaxing music.
  4. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake. - ans 3 4 Fill in the blank:
  5. _______ is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. ________, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. - ans1 & 2 = collaboration health promotion (injury prevention-suffocation): infant (birth-1 yr) - ans-avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing How should you respond when client wants to discontinue dialysis - ans"What has changed to make you decide this?" = Seek clarification from client to establish mutual understanding while staying therapeutic How to prevent adverse effects of oxycodone - anscan cause respiratory depression. What is the nursing intervention and/or client education? Monitor vital signs. › Stop opioids for respiratory rate less than 12/min, and notify the provider. › Have naloxone and resuscitation equipment available. › Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines, consumption of alcohol). hypotension is classified with a reading below normal; - anssystolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation Identifying manifestations of transient ischemic attacks - anssymptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke. If a patient has anorexia nervosa and works out constantly - ansAllow them to workout and continue their regimen includes the group when decisions are made Motivates by supporting star achievements Communication occurs up and down the chain of command

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

Work output by staff is usually of good quality-good when cooperation and collaboration is necessary - ansDemocratic Interaction of diuretics and ACE inhibitors - ansexcessive reduction in blood pressure and symptomatic hypotension or hyperkalemia involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of time - ansdysfunctional grief Levothyroxine effects - ansUsed to restore client's metabolic rate

  • Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension Long term effects of NSAIDS (Ibuprofen) - ansGastric Ulcerations, perforations, hemorrhage, hypertension makes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings - ansAuthoritative makes very few decisions and does little planning motivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situation - ansLaissez faire Malnourished COPD patients - ans(1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soup Most managers can be categorized as - ansauthoritative, democratic, and laissez faire Multiple Sclerosis Patient - ansMitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug)
  • Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone)
  • Vomiting = causes dehydration
  • Hair Loss = emotional distress
  • Amenorrhea = emotional distress Musculoskeletal congenital disorders - ansMonitor skin for breakdown areas and prevent pressure sores. Nurses must follow what code of standards in delegating and assigning tasks - ansANA codes of standards opioid agonists can cause Constipation

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan?

  1. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.
  2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease.
  3. The family should support the client to help reduce feeling of low self-esteem and isolation.
  4. The client will be required to take prescribed medication for a duration of 6- months. - ans The nurse caring for a child in Buck's skin traction will keep the: - ansChild pulled up in bed The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective?
  5. The client advances the cane 18 inches in front of her foot with each step.
  6. The client holds the cane in her left hand.
  7. The client advances her right leg, then her left leg, and then the cane.
  8. The client holds the cane with her elbow flexed 60°. - ans The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Green color and texture b) Black and tarry appearance c) Clay-like quality d) Bright red blood in stool - ansB The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
  9. Take the client to the dining room with 1:1 supervision.
  10. Inform the client he may go to the dining room when he controls his behavior.
  11. Hold the meal until the client is able to come out of seclusion.
  12. Serve the meal to the client in the seclusion room. - ans The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST?
  13. "Take three deep breaths, hold your incision, and then cough."
  14. "That was good. Do that again and soon it won't hurt as much."
  15. "It won't hurt as much if you hold your incision when you cough."
  16. "Take another deep breath, hold it, and then cough deeply - ans The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient
  17. with his neck in a midline position and the head of the bed elevated 30°.
  18. side-lying with his head extended and the bed flat.

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

  1. in high Fowler's position with his head maintained in a neutral position.
  2. in semi-Fowler's position with his head turned to the side. - ans The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?
  3. Return the client to usual activities of daily living.
  4. Maintain optimal function within the client's limitations.
  5. Prepare the client for a peaceful and dignified death.
  6. Arrest progression of the disease process in the client. - ans The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention?
  7. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago.
  8. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine.
  9. A client who has dysuria and foul-smelling, cloudy, dark amber urine.
  10. An immunosuppressed client who has not received an influenza immunization. - ans The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider?
  11. Paradoxical excitement.
  12. Headache.
  13. Slowing of reflexes.
  14. Fatigue. - ans The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations?
  15. The staff maintains a calm manner when interacting with the client.
  16. The staff attends to client's physical needs as necessary.
  17. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety.
  18. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety. - ans The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST?
  19. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can.
  20. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time.
  21. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain.
  22. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL. - ans

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

what are normal creatinine levels? what are normal BUN levels? - ans0.8-1.4 mg/dL 8-25 mg/dL What are positive actions to help others - ansBeneficience What are some things to teach about home safety with elderly patients? - ans- Removing items that could cause the client to trip, such as throw rugs and loose carpets

  • Placing electrical cords and extension cords that against a wall behind furniture
  • Making sure that steps and sidewalks are in good repair
  • Placing grab bars near the toilet and in the tub or shower and installing a stool riser
  • Using a non-skid mat in the tub or shower
  • Placing a shower chair in the shower
  • Ensuring that lighting is adequate both inside and outside of the home What are some ways to identify a patient before giving a medication? - ansThe Joint Commission requires 2 client identifiers be used when administering medications.
  • clients name
  • assigned identification number
  • telephone number
  • birth date or other personal-specific identifiers. Bar code scanners may be used to identify clients What are the five stages of grief - ansdenial anger bargaining depression acceptance What are the precautions for vancomycin resistant enterococcus - ansStandard precautions including hand washing and gloving should be followed What are the S/S of lithium toxicity? (depakote for bipolar disorder) - ansfine hand tremors, mild GI upset, slurred speech and muscle weakness What are the signs and symptoms of fluid volume deficit - ansloss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. What are the therapeutic effects of protamine - ansAntidote to severe heparin overdose + Reversal of heparin administered during procedures What are the values and beliefs that guide behavior and decision making? - ansMorals What are total serum protein values (normals) - ans6-8 g/dL What can be delegated to Assistive personnel (AP)? - ans- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients

QUESTIONS AND ANSWERS LATEST 2023-2024 TEST BANK

100 % COMPLETE

What can prevent MI, stroke, or death in high-risk patients - ansRamipril What comorbidities may be observed with a patient who is bipolar? - ansSubstance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD. What do the nurse need to keep in mind about the client when being their advocate? - ansClient's religion & culture What do you do when a client has a seizure - ans- lower to bed/floor

  • protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement What does a newborns poop look like - ansIf your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency what foods should you avoid if you have diverticulitis? - ansavoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber) What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given? - ansContraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should give = TDaP (Tetanus, Diphtheria, Pertussis) what is a normal hematocrit level in a female? What are normal Hgb values (female)? what are normal values for WBCs? - ans37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uL What is an agreement to keep promises - ansFidelity What is an interdisciplinary team? - ansA group of health care professionals from different disciplines What is appropriate for an adolescent in the hospital? - ansPuzzles and books What is avoidance of harm or injury - ansNon-maleficence What is bipolar disorder? - ansBipolar disorder is a mood disorder with recurrent episodes of depression and mania. What is fairness in care delivery and use of resources - ansJustice what is important about the diet of someone taking ACE inhibitors? - anscan result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas)