A nurse is checking the respiratory rate of a toddler, previously admitted with asthma. The child is crying and upset by the hospital and the process of taking her vital signs. What should the nurse do? Note respiratory pattern and rate, including a comment that child is crying Call the provider since the respiratory rate is 60 and extremely labored. Wait to assess respiration's until the child is not crying. Measure the respiratory rate before the temperature.
You have loosely applied a bed sheet around your client’s waist to prevent a fall from the chair. What have you done? Committed a crime Ensured the client’s safety which is a high patient care priority Violated Respondeat Superior Violated the client’s right to dignity.
The nurse is caring for an actively dying, unresponsive patient while the family sits at the bedside. The husband ask "Isn't she hungry? She hasn't had anything to eat in 24 hours" Which response by the nurse would be most appropriate? "Here is a menu- we can order some foods that she enjoys eating" "The body doesn't need food at this stage" "We should talk to the physician about placing a feeding tube to help with intake" "Motility of the stomach and intestines are decreased, so eating could make her nauseous".
What type of personal protective equipment would be appropriate for assisting with respiratory care of a pediatric patient with pertussis (whooping cough)? Gown, gloves and mask with eyes shield Gown and gloves Gown, gloves and mask Gown, gloves and respirator.
You measure your 5-year-old client’s vital signs as:
• Respiratory rate: 32 breaths per minute
• Pulse: 100 beats per minute
• Blood pressure: 55/85
The mother asks you if these vital signs are normal. You should respond to this mother’s question by stating:
“The respiratory rate is a little too fast, but the other vital signs are normal.” “All of these vital signs are normal for a child that is 2 years of age.” “The pulse rate is a little too fast, but the other vital signs are normal.” “The blood pressure is a little low, but the other vital signs are normal.”.
A baby is born prematurely at 26 weeks requiring ventilatory support. The nurse caring for this neonate knows that this because of which of following? Ineffective cough Bronchospam Lack of functioning alveoli Lack of surfactant.
A nurse is assigned to the care of a 2-year-old hospitalized child. When planning care, the nurse must give greater priority to which of the following interventions? Adapt the child to the routine of the hospital. Let the child participate in games and recreational activities. Offer constant care. Protect the child from damage.
Older adults may be at increased risk of injury related to physiologic factors. Which the following are relevant risk factors unique to this population? Select all that apply: TODAS EXCEPTO Alcohol impairment Decrease in sensory-perceptual function and cognitive judgment Medication side effects Impaired thermoregulation Alcohol impairment.
A nurse in the Medicine Unit is in the care of a Diabetic client with Senile Dementia. This nurse recognizes that, which of the following nursing interventions has the highest priority in preventing the risk of falls? Review the medications that were prescribed. Keep all rails elevated. Keep the client restricted. Keep the bed in the lowest position.
Nurse should be aware of various safety hazards in the workplace. Which of the following present safety hazards to nurse? Select all that apply: Needlestick injury Chemotherapy administration Cleaning solution spill Assisting with patient mobility or transfers. all of above.
A nurse obtains an oral temperature of 35.9°C on a 70-year-old woman before morning change or shift (05:00). Which is/are possible explanation for this reading? Select all that apply: Elderly adult may have a lower baseline temperature reading related to age. Postmenopausal state. Stress of hospitalization Time of day Elderly adult may have a lower baseline temperature reading related to age. and Stress of hospitalization.
In providing care for a client being treated for fluid volume excess, which of the following interventions would be best delegated to an experienced LPN? Select all that apply: Document hourly urine output Insert IV line Monitor EKG readings Check for the presence of pedal edema Measure weight Obtain vital signs every 30 minutes Document hourly urine output, Measure weight, Obtain vital signs every 30 minutes.
A nurse need to check an ill infant's temperature at the pediatrician's office. Which site would be most appropriate for this age? Ear Temporal artery/forehead Mouth Rectum.
In the event of a fire, what is the most important thing that a nurse needs to do? Close windows and doors and turn off oxygen Give patients wet washcloths to breathe through to reduce smoke inhalation Evacuate bedridden patients Determine which patients are in immediate danger.
You are a hospice nurse who, as part of your role, does follow up counseling and care for the significant others of deceased spouses for one year after their loss. Whose theory of grief and loss would you most likely integrate into your practice as you perform this role? Kubler Ross' theory Lewin's theory Warden's theory Engel's theory.
A 26-year-old patient is admitted from the recovery room and is identified as at risk for falls. Which of the following best describes the rationale for this nursing diagnosis? Depression Pain medication History o dizziness Confusion.
A child is exhibiting marked trouble breathing and complains of feeling short of breath. A high-pitched musical sound is heard on inspiration and expiration. How would the nurse best classify this dyspnea? Wheezing Stridor Unlabored Exertional dyspnea.
You are serving as the preceptor for a newly graduated nurse. As you observe the new nurse for their application of body mechanics principles into client care, you observe that the nurse spreads her legs apart during a transfer with a client. What should you do? Validate the nurse’s competency in terms of the application of body mechanics principles during a transfer. Advise the nurse that the legs must be close together for stability during lifting and transfers. Validate the nurse’s competency in terms of the application of ergonomics principles during a transfer. Advise the nurse that the legs should be one in front of the other and not spread apart during a transfer.
A patient is identified a Methicillin-resistant strains of Staphylococcus aureus (MRSA) in his sputum. Which of the following transmission routes would be most appropriate? Vehicle Airbone Droplet Contact.
A patient diagnosed with pneumonia is exhibiting an elevated temperature, high white blood count, and low blood pressure with increased heart rate. Which of the following would describe the patient's condition? Opportunistic infection Sepsis Infectious disease Nosocomial infection.
You assess your family as having a deficit in terms of their instrumental activities of daily living (ADLs). Which healthcare professional would you most likely refer this family to in order to address this deficit? An occupational therapist A social worker A speech therapist A physical therapist.
A nurse has a medical order to immediately obtain an excreta culture from his client. The nurse should avoid doing, which of the following actions when carrying out this intervention? Use a sterile container. Cool the specimen Use a sterile tongue depressor to collect the sample. Send the specimen directly to the laboratory.
The nurse is assessing the influence of external versus internal factors with a patient admitted with failure to thrive and malnutrition. Which of the following would be external factors that may affect this patient's health? Select all that apply: TODAS EXCEPTO Motivation to perform self care Proximity of grocery store Support network Ability to prepare food Motivation to perform self-care.
A nurse is educating a group of mothers on how to prevent accidental poisoning. Which of the following precautions should the nurse suggest about the management of the medications? Place the medicines in different containers. Use medicine bottles with lids approved by children. Enclosing all medications in a closet. Store medications on the top shelf of a closet.
A nursing assistant reports a blood pressure to be 70/49 mmHg with a heart rate of 126. What position would be most appropriate for the nurse to use with this patient? Trendelenburg Sims' Semi-Fowler's Lithotomy.
The nurse is caring for a patient newly diagnosed with metastatic lung cancer. What would be the most appropriate statement for the nurse to make regarding palliative care resources? "Palliative care is for when you have a prognosis of less than 6 months." "Palliative care can only be done once you discharge from the hospital." "Palliative care focuses on quality of life and may be used from the time of diagnosis." "One you decide that you don't want to receive further treatment, palliative care will help keep you comfortable.".
A 6-year-old boy returns from the operating room after a tonsillectomy. The child remains sleepy but wakes up easily. For safety, the nurse must place the child in Which of the following positions? Lateral Fowler Supina Prona.
The nurse is caring for an East African family that has just experienced a fetal demise at full term. The family initially refuses to see the stillborn infant. What should be the nurse do first? Assist family members to see the infant in order to gain closure. Ask the family about their expectations for mourning. Provide educational materials about loss of an infant. Evaluate the need for emotional and practical help.
A patient is having difficulty coughing up secretions, has rhonchi in the lungs, has respiratory rate of 28, and has dyspnea. The nurse recognizes these as symptoms of which nursing diagnosis? Impaired gas exchanged Ineffective breathing pattern Ineffective airway clearance Impaired deep breathing.
A nurse is providing skin care for a morbidly obese patient. Which of the following interventions are essential to prevent skin breakdown in bariatric patients? Select all that apply: Drying beneath the pannus Cleansing between thighs. Assessing behind ears when using a nasal cannula Elevating heels from bed Drying beneath the pannus, and Cleansing between thighs.
A nurse is in the care of a client who is frequently disoriented. Which of the following interventions should always the nurse implement to guarantee the client’s safety? Locate the bell where he can easily reach it. Perform frequent supervision rounds. Ask the family to hire a nanny. Keep all bed rails elevated.
The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for assigned clients. Follow up will be required if the LPN: Dons a clean glove on the dominant hand before tracheal suctioning Assesses a client’s apical pulse before administering Digoxin (lanoxin) Elevates the client’s stump on a pillow eight hours after amputation Positions a client on the operative side following a pneumonectomy.
You are caring for a hospice client who is at the end of life. Based on this client’s signs and symptoms, the client is comatose, dehydrated, free of pain, constipated, without distress and expected to die in a day or two. Which of the following is an appropriate client outcome or an appropriate intervention for this client? The client will be free of constipation The client will remain free of pain and distress The administration of an enema to correct the constipation The administration of an antiemetic to prevent vomiting and further dehydration.
An elderly patient admitted with malnutrition has positioning aids ordered. Which aids would be most appropriate for this patient? Elbow protector Bed cradle Trapeze Hand rol.
A patient is admitted with a cerebrovascular accident (CVA) and right-side weakness. Which nursing diagnosis is most appropriate? Impaired skin integrity Risk for self-care deficits Risk for disuse syndrome Activity intolerance.
A nurse is talking with a wife whose husband just expired. What would appropriate nursing interventions be for someone in the Shock Phase of the Grief Cycle Model? Select all that apply: Help mobilize a support system. Provide role models who have coped with similar loss. Encourage expression of diverse feelings. Help to establish coping behaviors used past. Help mobilize a support system and Help to establish coping behaviors used past.
A coworker states that he is not feeling well but says that he is fine to work. Two days later, he is out of work due to illness. What phase of the communicable period was he in when at work earlier in the week? Prodomal Incubation Convalescent Acute.
You measure your 2-year-old client’s vital signs as:
• Respiratory rate: 32 breaths per minute
• Pulse: 110 beats per minute
• Blood pressure: 55/82
The mother asks you if these vital signs are normal. You should respond to this mother’s question by stating:
“All of these vital signs are normal for a child that is 2 years of age.” “The pulse rate is a little too fast, but the other vital signs are normal.” “The blood pressure is a little low, but the other vital signs are normal.” The respiratory rate is a little too fast, but the other vital signs are normal.”.
After receiving report from the night nurse, which of the following patients should the nurse see first? A 55-year old woman complaining of chills who is scheduled for a total abdominal hysterectomy A 77-year old man with a nasogastric tube who had a gastrectomy yesterday A 42- year old man with left sided weakness asking for assistance to the commode A 30- year old woman who is 38 weeks pregnant complaining of a small amount of vaginal bleeding.
Which of the following terms best describes the synthesis of major features of decreasing risk of transmission of bloodborne pathogen and body substance isolation? Standard precautions Protective isolation Universal precautions Medical asepsis.
Which of the following impacts on the client’s preferences in terms of hygiene routines and practices? Diaphoresis Culture Locus of control Bodily surface area.
A nurse needs to take the blood pressure of a new patient admitted to the unit. The patient has an arteriovenous fistula in her left lower arm and a right- sided mastectomy. Which is the best site and proper technique to measure blood pressure on this patient? Right lower arm, appropriate-sized cuff, auscultate radial artery Left ankle, standard cuff size, auscultate dorsalis pedis Left thigh, appropriate-sized cuff, supine patient position Left upper arm, standard cuff size, auscultate brachial artery.
A nurse is caring for patient with COPD. In performing his assessment, he finds rounded, enlarged finger tips. He realizes that this is which of the following symptoms? Clubbing Dyspnea Arthritis Cyanosis.
After your assessment of your client and the need to transfer your client from the bed to the chair, what is the best and safest way to transfer this paralyzed client when you suspect that you will need the help of another for the client’s first transfer out of bed? Use a mechanical lift. Use a gait belt. Notify the client's doctor that the client cannot be safely transferred by you. Use a slide board.
In admitting a client with confusion and labile affect, the nurse discover that the client recently lost his son in a motor vehicle accident. Which nursing diagnosis best describe this client? Dysfunctional grieving Anticipatory grieving Impaired family process Ineffective health maintenance.
Which of these clients is at greatest risk for falls? A 77-year-old female client in a client room that has low glare floors. A 27-year-old sedated male client. An 87-year-old female client in a client room that has low glare floors. A 37-year-old male client with impaired renal perfusion.
A nursing student is checking an apical pulse on a patient who has just returned from surgery. Which of the following is an important element of this procedure? Count the first audible pulsation as "one" Count the pulse for 60 seconds. Place the diaphragm of the stethoscope at the third intercostal space at the midclavicular line. Count S1 and S2 sounds separately.
A client is immobile. Which nursing intervention would best improve tissue perfusion to prevent skin problems? Changing incontinence pads as soon as they become soiled Performing range-of-motion exercises, and turning and repositioning the client Assessing the skin daily Massaging any erythematous areas on the skin.
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