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Fundamentals Comprehensive Final Study Guide Spring 2011

** I put page numbers when it was included and I read through some rationales and if they were really good or straight from the book I included it in the answer for supplemental purposes, otherwise its just page numbers and you guys can make the rationale yourself =] ** P.S. A) There were several questions that a lot of us got wrong. If you dont see your rational its probably because I was copying and pasting off another test before I got to see yours. So dont feel bad; Im sure yours was just as great. B) Suggestion: dont memorize the letter of the correct answer but instead understand why it is the correct answer so you can find it regardless if it isnt in the same order on the final.

EXAM 1 Chapters 4, 15, 16, 17, 18

1. 2. Although there are similarities in the different nursing theories, there are key elements that distinguish one from another. The emphasis of Jean Watsons conceptual model is that: D) Caring is central to the essence of nursing (51) 3. 4. The Nurse realizes that which of the following stated client needs has the highest priority? D) An asthmatic clients concern regarding the lack of insurance to pay for her medications (28) 5. The nurse is working within a health care system that employs Neumans Theory. A client is having difficulty breathing and requires oxygen and medication. Within Neumans Theory, the nurse approaches the clients to: D) Strengthen the line of defenses at the secondary level of prevention (49) 6. Leiningers theory of cultural care diversity and university specifically addresses: A) caring for clients from unique cultures (50) 7. 8. The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address? D) Implementation 9. Youre planning to palpate the abdomen of your patient, Which part of the Examiners hand is best for palpating vibration? D) Ulnar surface 10. There are a variety of levels of critical thinking. An example of critical thinking at a complex level is: D) Discussing various alternative pain management techniques. (218) 11. Mrs. Berger is a 39yr old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process? D) Auscultation (53) 12. 13. Which of the following nursing actions is the best example of problem solving? C) Trying several difficult wound dressings to determine which one the client can apply the most effectively (220) 14. Which of the following clients should be prioritized with the most urgent need of nursing assessment. D) An asthmatic clients concern regarding the lack of insurance to pay for her medications. (262)

15. During percussion, the downward snap of the striking fingers should originate from the? B) forearm (663) 16. 17. 18. The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning? C) What do you think has been causing your current depression? -- The use of such openended questions prompts clients to describe a situation in more than one or two words (239) 19. After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data? B) Elevated blood pressure -- Objective data are observations or measurement of a clients health status (234) 20. 21. The process of data collection should be begin with the nurse performing A client interview -- The first step in establishing database is to collect subjective information by interviewing the client (236) 22. During an interview, the nurse needs to obtain specific information about the signs and symptoms of the clients health problem. To obtain these data most efficiently, the nurse should use: B) open-ended questions -- open-ended questions give the client a chance to open up freely, and prompts clients to describe a situation in more than one or two words (239) 23. The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication? D) Could you give men an example of how you handle stressors? (239) 24. The nurse is performing a problem focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain? D) Can you rate your pain using the pain scale that we discussed? 25. Which of the following questions will provide the nurse with the best understanding of a terminally ill clients spiritual needs? Are there any spiritual needs you have that I may help with 26. Which of the following statements made by the nurse should be included in the orientation phase of the nursing interview? . A Your answers will be kept confidential. B My name is Susan Smith and I am a registered nurse. D I need to ask you some questions that will help with planning your care. E Only those directly involved with your care will have access to your information.

27. When asked to define nursing diagnosis the nurses best response is? D) It focuses care a licensed nurse can provide with the identified needs of a client. -- a clinical judgment about individual family or community responses to actual and potential health problems or life processes. (248-249) 28. Of the following statements, which one is an example of and appropriately written nursing diagnosis? C) Ineffective airway clearance related to increased secretions (250) 29. 30. The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur? Impaired gas exchange (251) 31. The nurse recognizes that which one of the following statements is true with regarding to formulation of the nursing diagnoses. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life process (284) 32. 33. Which one of the following is a NANDA International diagnosis label? C) Risk for impaired parenting -- Diagnostic labels include descriptors used to give additional meaning to the diagnosis (253) 34. Mr. green is a 68 yr old patient who has complained of pain. As the health care provider, you have decided to use pain scale for documentation of the patients pain. The value of the use of scales for patients to rate their pain intensity is that: C) The patients response to therapy can be documented 35. Which of the following responses best reflects an understanding of the purpose of the related phrase attached to the diagnostic label deficient knowledge regarding postoperative routines? C) To provide for individualization of the nursing interventions 36. Which of the following assessment finding best supports the nursing diagnosis of the pain in right knee joint related to degenerative process? Client is observed grimacing when walking (242) 37. 38. 39. 40. Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The intervention statement Nurse will apply warm, wet soaks to the patients leg while awake lacks the following component? C) Frequency (267)

41. 42. 43. Expected hair distribution changes in older adults includes: C) Increased terminal hair follicles to the tragus of mens ears (175) 44. A client is experiencing nausea and abdominal distention postoperatively; the nurse initiates the interventions listed below. Which of the interventions are examples of independent interventions? (choose all that apply). A) Control aversive odors or unpleasant visual stimulation that trigger nausea B) Provide frequent moth care (268) 45.

EXAM 2 CHAPTERS 19, 20, 26, 32

1. 2. 3. An example of a cognitive nursing skill is: D) Recognizing the potential complications of a blood transfusion (284) 4. When does implementation begin as the fourth step of the nursing process? After the care plan has been developed -- Implementation, the fourth step of the nursing process, formally begins after the nurse develops a plan of care (P. 279). 5. Which of the following interventions is the best example of an indirect intervention directed towards client safety? D) Turning on a night light to illuminate the path to the bathroom-- Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients (P. 279; 813) 6. Which of the following statements best reflects the nurses understanding of the function of client reassessment? D) Since the client has been ambulating to the bedroom without difficulty, Ill walk with him to the dayroom after dinner. (281) 7. Which of the following examples is a nurse applying critical thinking attitudes when performing a dressing change. C) Showing confidence in the knowing which dressing materials to use (279) 8. The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be: D) Goal partially met; client able to state three symptoms -- If the clients behavior begins to show changes but does not yet meet criteria set, the goal is partially met (296) 9. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on evaluation, what should the nurse do next based on the nursing process? D) Reassess the client to determine the reason satisfactory pain relief has not been achieved (297) 10. Client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. A positive evaluation will focus upon C) the lungs being clear bilaterally on auscultation (296) 11. Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided? C) Pressure ulcer on the left heel is no longer producing purulent drainage (297)

12. Statements made by the clients family that gives the most reliable for use in the evaluation of a clients outcome is: A) Mom has been eating 90% of all meals since she has been home -- It is a measurable statement which is what is necessary for reliability (296) 13. A nurse caring for a client with pneumonia sits the client up in bed and suctions the clients airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the clients lung sounds and provides a glass of water for the client. Which of the following is an appropriate evaluative criterion used by the nurse? (Choose all that apply.) B Clients lungs are clear to auscultation in bases. D Clients rate and depth of breathing are normal with head of bed elevated. (294) 14. A client is recovering from surgery for removal of an ovarian tumor. It is one day after her surgery. Because she has an abdominal incision and dressing, the nurse had selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis? B) Clients wound will remain free of infection by discharge -- indicates resolution of a nursing diagnosis or maintenance of a healthy state which is the definition of a goal (293) 15. An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following? The witnessing nurse completes the report (388 Table 26-1) 16. Which is the most appropriate notation for a nurse to use according to the guidelines that should be followed when documenting client care? 0830 increased IV fluid rate to 100 mL/hr according to protocol 17. 18. The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse: D) Dates and signs all of the entries made in the record -- TJC standards require that all entries in medical records are dated and a method is established to identify the authors or entries (389) 19. The client developed a slight hematoma on his left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevated the forearm. The client states, My arm feels better What is documented as the R in focus charting? B) My arm feels betterData, Action, Response (391) 20. Which of the following is evaluated as a legally appropriate notation? B) Verbalized sharp, stabbing pain along the left side of chest -- Documenting is a story like format to document information specific to clients conditions and nursing care. (pg.390)

21. To avoid legal risks and possible lack of confidentiality associated with computerized documentation many programs currently have: Periodic changes in staff passwords 22. Which of the following nursing reflects the best understanding of the role of documentation and the Medicare reimbursement policy? D) The hospital is reimbursed for the nursing care documented in the client chart. -- Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs. (pg.385) 23. 24. 25. Accurate entries showing good written documentation such as: D) Client up, out of bed, walked 50 feet and back down the hallway with assistance from the nurse, HR 88 and regular before exercise, 94 and regular following exercise Realistic, measurable, and accurate w/ exact measurements (389) 26. A child that has eaten a popsicle will interfere with the accuracy of the temperature measurement therefore, it is best to: D) Wait 20 minutes before assessing the oral temp (537) 27. The client appears to be breathing faster than before. The nurse should: C) Count the clients rate of respirations -- Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured (529, 532) 28. The appropriate site for taking the pulse of a 2 year-old is: B) Apical -- The apical pulse is the best sight for assessing an infants or young childs pulse because other peripheral pulses are deep and difficult to palpate accurately (521) 29. Nurse is checking the vital signs of a newly admitted client with fractured femur. The client denies any history of HTN. The nurse should: C) Ask the client is she is having pain because it is a symptom of HTN (537) 30. A client with bilateral casts on the upper extremities should have the BP taken on the leg. The nurse expects the diastolic pressure to be: D) essentially the same as that in the brachial artery -- Systolic pressure in the legs is usually higher by 10 to 40 mm than in the brachial artery, but the diastolic pressure is the same (546)

31. The nurse has just taken vital signs for a 30 year old client. Based on the results the nurse will report the following finding that is out of expected range for a client of this age Pulse = 110 beats/min 32. Determine whether the following factor (Morphine) increases or decreases the respiratory rate. 33. 34. When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 -year-old child to: C) Assess the thermometer for five minutes (517) 35. The postoperative vital signs of an average size adult client are: BP 110/68mm Hg, P 54 beats/min, R 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should: D) notify the physician 36. A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, I feel dizzy. The nurse should: C) Assist the client into a sitting position 37. A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant: A) Wraps the cuff too loosely around the arm (545) 38. The client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include: D) Application of a cooling blanket (520) **argument was that B) Ice packs to axillae and groin is also correctpretty sure prof rose accepted both** 39. 40. After measuring the clients vital signs, the nurse obtains the following results: blood pressure= 180/100 mm Hg, pulse= 82 beats/min, R= 16 breaths per min, and rectal temp= 37.5 C. The nurse should: B) Retake the clients temperature 41. A client is being monitored with a pulse oximetery on review of the following factor the nurse suspects that the values will be influenced by: B) A diagnosis of peripheral vascular disease (530 Skill 32-3) 42.

43. A 52 year old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 pounds. Which vital sign should not be delegated to a nursing assistant? B) Respiratory rate (529) 44. Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)? B) A pierced earlobe of a client with a closed head injury whose nail capillary refill times is 3.5 seconds 45. An 82 year old man arrives at the emergency department with an oral body temperature or 38.3C (101 F), a pulse rate of 114/min, and respiratory rate of 22/min. He is restless and his chin is warm to the touch. Which of the following are appropriate nursing interventions for this client (select all that apply) B. Obtain culture specimens before initiating prescribed antimicrobials D. Allow for adequate rest E. Provide oral care F. Apply an additional blanket if the client feels chilled

EXAM 3 CHAPTERS 9, 24, 38

1. The nurse recognizes the following as an appropriate strategy for communicating with clients who are not fluent in English. B) Incorporating hand gestures and pictures (115 box 9-3) 2. From culture to culture time after takes on different meanings. In exploring time to nursing interventions the nurse should: C) Maintain a flexible attitude when the client requests procedures to be done at specific times -Improving clients access to health services mandates culturally congruent time schedule that accommodate his or her cultural patterns (118- 119) 3. While going through the process of acculturation a client will be: Adapting to and adopting a new culture (108) 4. When faced with a scenario where it is believed that a client from another cultural background is using herbal remedies along with the prescribed medication to treat her arthritis. The nurses first action should be to: C) Ask the client to identify what herbal remedies are being used along w/ the prescribed medications (110) 5. 6. In order for nursing students to enhance their cultural awareness, students will need to make an in depth self- examination of their B) Background, recognizing their biases and prejudices -- that cultural awareness is an in depth self examination of ones own background, recognizing biases and prejudices and assumptions about other people (108-109) 7. 8. Cultural competence is the process of: C) Acquiring specific knowledge, skills, and attitudes -- Culturally competent care requires specific knowledge, skills, and attitudes in the delivery of culturally congruent care (108) 9. The nurse is in the process of conducting an admission interview with the client. At one point in the discussion, the client has provided information that the nurse would like to clarify. The nurse employs the technique of clarification as indicated by the response: A) Im not sure that I understand what you mean by that statement -- Despite efforts at paraphrasing, sometimes you will not understand the clients message and you need to let the client know if this is the case. (354) 10. 11.

12. A client is admitted for a CAT scan (diagnostic test) of the cranium. As the nurse explains this diagnostic test, the client moves away from the nurse. This is an example of what influencing factor in communication? C) Space and territoriality -- During interpersonal interaction, people maintain varying distances between each other depending on their culture, the nature of their relationship, and the situation. When personal space becomes threatened, people respond defensively and communicate less effectively (354) 13. 14. A nurse is bathing an older client and says to him, turn to your side now, honey. The nurse believes she is demonstrating warmth and caring by calling the client honey. However, the client finds the term offensive. What has caused this miscommunication to occur? C) The connotative meaning of the word is different to the client and the nurse.(348)

15. 16. A helping relationship is being established between nurse and client. In addressing the client, the nurse should: Always knock and pause before entering the clients room (348) 17. When working with a client with aphasia, the nurse may attempt to enhance communication by: Using visual cues (349) 18. Which of the following statements best reflects the clients positive feedback to the nurses question. Do you understand how to check your blood sugar? D) Demonstrating finger stick to the nurse (355) 19. The nurse can best detect that a client needs clarification of information provided on a special diet by: B) Assess clients nonverbal cues that suggest confusion -- Nonverbal communication is unconsciously motivated and more accurately indicates a persons intended meaning that the spoken wordsnonverbal body cues represent 55% of communication (344) 20. A nurse provides a brief but concise orientation to the use if the rooms telephone and television to a newly admitted older client experiencing abdominal pain. The clients daughter later reports that the father has attempted to call her but was never shown how to use the phone. The most likely cause for the clients apparent lack of knowledge retention is: B) The pain distracted him from focusing on the information when it was provided (346) 21. Supporting a client by holding onto her elbow while accompanying her as she ambulates around the nursing unit is considered social touching and so would be typically Considered non-threatening by the client (354) 22. Which of the following is appropriate when using an interpreter to communicate with a client and his family (select all that apply) B) Ask the family one question at a time

C) Use lay questions if possible D) Do not interrupt the interpreter and the family as they talk 23. A nurse recognizes that a helping relationship is established with a client if the communication? Encourages The client to express his thoughts and feelings 24. 25. Gasoline is class B, electrical wiring is class C, and cardboard is class A **this was a matching question about types of fire extinguishers** 26. The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs? C) Carbon dioxide levels should be monitored in home settings 27. A 79-year-old resident in a long-term care facility is known to wander at night and has fallen in the past. Which of the following is the most appropriate nursing intervention? B) The client should be checked frequently during the night 28. 29. In a nursing home an elderly client drops his burning cigarette in a trash can and starts a fire. The most appropriate type of fire extinguisher to use is? A) Type A-- Class A is cardboard, wood, clothe, paper and many plastic items. A ciggarette would be a class A fire. (p.840) 30. 31. The nurse assesses that the client may need a restraint and recognizing that? D) Restraints are to be periodically removed to have the client reevaluated -- An order for restraints to be implemented until no longer needed by a client is a good goal but once again, reevaluation and repeat of the nursing process gears the focus of patient health improvement. (P.834) 32. Which of the following nursing interventions has the greatest likelihood of minimizing the risk of injury for a client who frequently gets out of bed at night to go into the bathroom? A) Limiting fluid intake after 6 pm OR B) Illuminating the pathway to the bathroom 33. When discussing the prevention of fire- related injuries and deaths, the nurse should place the greatest emphasis on the: B) Dangers of careless smoking habits-- The leading cause of fire-related death is careless smoking. (p, 813) 34. The nurse is preparing a safety-related program for a group of parents of 5 to 14 year olds. Which of the following topics is most likely to positively impact the leading cause of injury for this age- group? B) Bicycle riding with safety in mind -- Children 5 to 14 years of age account for nearly one third of bicyclists killed in traffic accident (815)

35. A nurse working in an acute care facilitys emergency department should recognize which of the following client reports as being most suspicious of a terrorist attack? C) 15 causes of nausea and vomiting reported over a 2-day period when 4 cases would be within normal for the facility -- Features that alert nurses to the possibility of a bioterrorism-related outbreak include the following: A rapidly increasing incidence (within hours or days) of a disease in a normally healthy population; an unusual increase in the number of people seeking care, especially with fever, respiratory, or GI complaints; an endemic disease rapidly emerging at an uncharacteristic time or location or in an unusual patter; lower attack rate among clients who are primarily indoors, in areas with filtered or closed ventilation compared with people who had been outdoors; clusters of clients arriving from a single locale; large numbers of rapidly fatal cases; any client presenting with a disease that is relatively uncommon to the geographical area and has bioterrorism potential; and atypical clinical presentation. (p.821). 36. Which of the following assessment finding is most critical in a client who is currently being restrained with mechanical wrist restraints D) Hands are cool to touch -- Frequent assessment prevents complication, such as suffocation, skin breakdown, and impaired circulation. (p.835, 837) 37. A nurse caring for an elderly client who has had surgery and is in the hospital knows that the client is at high risk for developing a nosocomial infection. One of the most important things that the nurse can do to prevent this client from obtaining a nosocomial infection (hospital acquired) is to: Practice appropriate hand hygiene (642) 38.

39. During the night shift a client is found wandering the hospital halls looking for a bathroom. The nurses initial intervention would be to: D) Provide scheduled toileting during the night shift 40. A couple is with their adolescent daughter for a school physical. The parents tell you that they are worried about all the safety risks affecting this age. As you plan to teach the parents about these risks, you remember that adolescents are at a greater risk for injury from: Poisoning and child abduction (828)

EXAM 04 CHAPTERS 34, 48, 47, 37

1. While working with clients in the postoperative period, the nurse is very alert to the results of laboratory tests. Which one of the following results is indicative of an infectious process? C) WBC 18,000/mm3 (pg 651) 2. The nurse is observing the new staff member work with the client. Of the following activities, which one has the greatest possibility of contributing to a nosocomial infection and requires correction? C) Placing a Foley catheter bag on the bed when transferring a client -- drainage bag that touches a possible contaminated surface can spread infection (648 box 34-2) 3. 4. A nurse must display understanding of the mental implications of a client on isolation precautions when planning care to control the risk of: D) Isolation --When a client requires isolation in a private room, a sense of loneliness may develop because normal social relationships become disrupted. Isolation in a private room limits sensory contact. (pg 622) 5. Surgical aseptic techniques are employed by a nurse when: A) Inserting an IV catheter (Use surgical asepsis in the following situations): during procedures that require intentional perforation of the clients skin, such as insertion of IV catheters or central lines (pg 669) 6. A nurse is changing the dressing and accidentally drops the packing onto the clients abdomen. The client has a large, deep abdominal incision that is packed with sterile half-inch packing and covered with a dry 4x4 gauze. The nurse should: Throw the packing away and prepare a new one 7. A client has a viral infection. Which of the following is typical of the illness stage of the course of her infection? B) An oral temperature reveals a febrile state (646) 8. 9. A client with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this client to the unit will require the implementation by the staff of: A) Airborne precautions -- Airborne precaution is droplet nuclei smaller than 5 mcg; measles, chicken pox, disseminated varicella zoster, pulmonary and laryngeal TB (pg 663) 10. 11. A client has requires a mid-abdominal surgical incision which necessitates a sterile dressing. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: B) Discard packages that may have been in contact with the area below waist level -- to maintain the sterile field nothing must come in contact with the sterile field. Any item included in the sterile field must be discarded immediately after contamination.

12. A nurse is caring for a client who has colonized methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements reflects the best understanding of the clients condition? A) This client has the bacteria present but it hasnt become infected. -- MRSA Colonization is the term used to describe those who have drug resistant staph aureus bacteria on or in their bodies but have not yet become ill through the infection of a wound or other area of tissue. 13. A pre-surgical client asks the nurse why it seems so easy to get an infection in the wound after surgery. The nurses most appropriate response to this question is: D) The surgical wound provides the microorganisms on the surrounding skin a path to enter deep into the bodys tissue -- Individuals who have compromised health or defenses against infection includes those who have had surgery. A component of the chain of infection includes a reservoir where the infectious agent grows on wound drainage. (ATI pg. 92) 14. 15. A client is admitted for treatment of variously poorly healing infected leg ulcers. The nurse recognizes that the clients nutritional history is the primary importance since? C) Wound healing and infection prevention are negatively impacted by poor nutrition (646) 16. The nurse is providing care for a client who postoperatively has developed an infected incisional wound and is depressed an anorexic. Which of the following nursing interventions has priority? A) Sterile wound care -- surgical asepsis or sterile techniques prevents contamination of an open wound, and served to isolate further infection (669) 17. While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode should first: C) Lower the client gently to the floor. 18. A client is admitted to the medical unit following a CVA. There is evidence of left-sided hemiparesis and the nurse will be following up on range of motion and other exercises performed in physical therapy. The nurse correctly teaches the client and family members which of the following principles of range of motion exercises? A) Flex the joint to the point of discomfort -- Carry out movements slowly and smoothly, just to point of resistance; ROM should not cause pain (1274) 19. 20. Following an assessment of the client, the nurse identifies the nursing diagnosis activity intolerance related to increased weight gain and inactivity. An outcome identified by the nurse should be: C) Exercise will be performed 3 to 4 times over the next two weeks -- For activity tolerance it states: Client will perform record exercise patterns 3 to 4 times over the next 2 weeks (798) 21. Which of the following nursing interventions is likely to have the most impact on reducing friction when positioning an immobile client? C) Dressing the bed with a lift sheet to be used during the transfer -- For a client unable to assist. A. Ask appropriate staff to help, B. Select appropriate safe handling device (friction-reducing device), C. Use friction-reducing device or full body sling (pg 1253)

22. The nurse has delegated the task of ambulating a client who is experiencing activity intolerance. Which of the following statements made by the nurse best reflects an understanding of the nurses role to properly instruct the ancillary personnel regarding this task? A) Stop the walking if the client complains of pain or weakness 23. Which of the following nursing assessment. Questions will best determine the nature of an exercise related injury? B) Tell me what is included in your typical workout routine. 24. The first rule of safety when managing client transfer is: C) Use lift teams or mechanical lifts when the transfer requires it -- must have the safety of the patient as well as yourself in mind. Assess every situation that involves client handling and movement to minimize risk for injury (1260) 25. 26. A client is leaving for surgery and because of preoperative sedation needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first? D) Assess the situation for any potentially unsafe complication 27. An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as C) diminished breath sounds -- Atelectasis is the collapse of alveoli. In atelectasis, secretions block a bronchiole or bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Mucus accumulated in the dependent regions of the airways. (1226) 28. A client is getting up for the first time after a period of bed rest. The nurse should first: B) Obtain a baseline BP -- Although not all clients will experience orthostatic hypotension, nurses monitor clients vital signs during the first few attempts at sitting or standing (1239) 29. Antiembolic stockings (TED hose) are ordered for the client on bed rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is to: C) Apply external pressure -- Elastic stocking (sometimes called thromboembolic device [TED] hose) also aid in maintaining external pressure of the muscles of the lower extremities and thus promote venous return. (1248) 30. To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse should implement the use of B) High-top sneakers -- Apply positioning boots, or high-top tennis shoes on clients feet to prevent foot drop by maintaining the feet in dorsiflexion. (pg 1251)

31. It has been determined that all of the following clients are at risk for falling. Which one requires the nurses priority for ambulation C) An 81 yr old who is asthmatic and had a hip replacement 18 months ago

32. A 16 year old had a full leg cast for 4 months and it is being removed today. Which of the following statements made by the client shows the most informed understanding of effects of immobiliazation of a muscle on its strength and stamina: C) Ill practice the strengthening routine the physical therapist taught me so I can play baseball in the spring -- collaborate with other health care team member such as physical or occupational therapists when considering mobility needs (788; 1223; 1241) 33. Which of the following statements made by a nurse caring for a client who experiences a myocardial infarction 8 hrs ago shows the greatest insight as to the purpose for keeping the client on bed rest: C) Keeping her on bed rest decreases the need her body has for oxygen (1225 - - Box 47-1) 34. 35. 36. The nurse determines that the clients wound may be infected. To perform an aerobic wound culture the nurse should: C) Obtain a culturette tube and use sterile technique -- To perform an aerobic wound culture you need to first clean the wound with normal saline to remove any slough and then obtain a culturette tube and use sterile technique. 37. 38. The nurse notes a clients skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: B) Stage II 39. The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the clients skin integrity? C) Keeping a written schedule of turning and positioning -- A written schedule of turning and positioning reduces the chances of skin break down from occurring from the continuous changing of positions (p. 1252). 40. Upon changing the clients dressing the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is: A) Sterile saline -- For a granulating wound absent of exudate and swelling should be irrigated with normal saline to maintain a healthy wound environment (1282, 1310) 41. The nurse prepares to irrigate the clients wound. The primary reason for this procedure is to: Remove debris from the wound 42. 43. Upon inspection of the clients wound, the nurse notes that is appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select based on the wound assessment in: C) Foam -- Foam dressing has larger pores and is most effective (1321-1324)

44. A client comes to the emergency department following an injury. The nurse implements appropriate first aid for the client when: B) Elevating an affected part that is bleeding (1294) 45. The nurse is concerned that the clients midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication? D) Placing a pillow over the incision site when the client is deep breathing or coughing 46. Following a head injury, the client has thin clear drainage coming from the left ear. The nurse describes the drainage as: A) Serous -- Clear, watery, plasma (1287) 47. Which nursing entry is most complete in describing a clients wound? D) Incisional edges approximated without redness or drainage, 2 4x4s applied -- Wound classification systems describe the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, or descriptive qualities of the wound tissue such as color (1284) 48. The client is scheduoes for a dressing change when removing the adhesive tape used to secure the dressing the nurse should lift the edge and hold the tape: D) Parallel to the skin while pulling toward the wound - - To remove tape safely, loosen the tape ends and gently pull the outer end parallel with the skin surface toward the wound (1320; 1283) 49. The nurse is aware that application of cold is indicated for the client with: C) A fractured ankle - - Examples of conditions treated: direct trauma (sprains, strains, fractures, muscle spasms); superficial laceration or puncture wound; minor burn; suspected malignancy in area of injury or pain; injections; arthritis and joint trauma (1335 Table 48-11) 50. The client requires a support, and an abdominal binder is ordered. The nurse correctly implements the use of a binder by: Making sure the client has adequate ventilator capacity 51. The client is experiencing low back pain and is to have an aquathermia pad applied. The nurse recognizes that safe application of heat to a clients injury includes: Providing a timer for the client 52. Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client? 2 cm area purplish blue in color surrounded by lighter-colored skin located on right heel

53. The 23 year old female client is concerned about scarring from her hernia surgery. She has a third degree burn on her right arm when she was younger that left a scar that she is self-conscious about. The nurse explains to the client that the wound from the burn healed differently that the surgical incision will heal. The incision that she will have will heal by: A) primary intention -- primary intention is a wound that is closed and after surgery (1284)

54. Proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? A. Presence of pain B. Depth of damage C. Length and width D. Presence of drainage E. Description of drainage F. Condition of surrounding tissue

EXAM 05 CHAPTERS 43, 35, 44

1. The nurse should describe pain that is causing the client a burning sensation in the epigastric region as: Deep visceral - - Deep or Visceral pain is diffused and radiates in several directions. An example is a crushing sensation (e.g. gastric ulcer) (pg 1064) 2. Which of the following is most appropriate when the nurse assess the intensity of the clients pain? C)Offer the client a pain scale to objectify the information 3. 4. An older client with mild musculoskeletal pain is being seen by the primary care provider. The nurse anticipates that treatment of this clients level of discomfort will include Acetaminophen (1074) 5. Inserting a Foley Catheter, the nurse explains that the client may feel some discomfort. This is an example of ? D) self-care maintenance (1071) 6. The nurse knows that the PCA pump would be most appropriate for the client who? C) Experiences renal dysfunction (1058) 7. A client with chronic back pain has an order for a transcutaneous electrical nerve stimulation (TENS) unit for pain control. The nurse should instruct the client to: B) Use the unit when pain is perceived -- The client turns the transmitter on when feeling pain. This creates a buzzing or tingling sensation. The client may adjust the intensity and quality of skin stimulation. The tingling sensation can be applied until pain relief occurs. TENS is effective for postsurgical and procedural pain control (1073) 8. Nurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct? The client is the best authority on the pain experience 9. A nonpharmacological approach that the nurse may implement for clients experiencing pain that focuses on promoting pleasurable and meaningful stimuli is: B) Distraction -- distraction inhibit painful stimuli if a person receives sufficient or excessive sensory input (1071) 10. Which of the following statements made by a nurse shows the greatest understanding of the personal nature of the pain experience? B) Use when Pain is perceived -- The client turns on the transmitter when feeling pain (1073) 11.

12. The nurse inquired of a postoperative client as to the need for pain medication. The client denies the need then but 30 minutes later reports, I am really in a lot of pain. Can you bring me my pain pill now? The nurse recognizes that the most immediate need for client education is related to explaining that: D) His pain will be more effectively managed if he reports a need for pain medication while the pain is still tolerable (1075 Box 43-13) 13. The nurse is caring for a cognitively impaired client who has experienced a painful procedure. The nurse is most effective in determining the clients pain medication needs when using which of the following assessment methods? D) Observing the clients body movements and facial expressions for typical pain (1065) 14. A client with chronic pain states, I just want to be pain free. Do something to make that happen. The most therapeutic response is: Together we will make your pain more tolerable (1071) 15. Which of the following statements is the most appropriate response to a clients statement, I thought you could tell I was in Pain? I will make a point of asking you to rate your pain at least every 2 hours, so this miscommunication wont happen again. (1062) 16. 17. Taking into consideration the hospice clients chronic pain from bone cancer, the most appropriate person to collaborate with regarding management of pain is: D) An oncology nurse 18. A client is nauseated has been vomiting for several hours, and needs to receive an antiemetic (antinauseated) medication. The nurse recognizes that which of the following is accurate? C) A parenteral route is the route of choice -- A parenteral injection or injection of any type is always the fasted. Parenteral administration involves injecting a medication into body tissues. (693) 19. 20. The student nurse reads the order to give a 1-year-old client an intramuscular injection. The appropriate and preferred muscle to select for a child is the: D) Vastus lateralis often used for infants, toddlers, and children receiving biological (752) 21. The client is ordered to have eye drops administered daily to both eyes. Eye drops should be instilled on the: C) Lower conjunctival sac 22. Following the administration of ear drops to the left ear, the client should be positioned: C) Right lateral -- should ask the client to remain in side-lying position 2-3 minutes after the instillation of ear drops. (728) 23. The most effective way in the acute care environment to determine the clients identity before administering medications is to: Check the clients name band

24. 25. A priority for the nurse in the administration of oral medications and prevention of aspiration is A) Checking for a gag reflex (717) 26. The nurse is caring for a client who is experiencing severe pain and is insistent about getting some relief quickly. Which of the prescriptions is more likely to produce quickest pain relief? D) Morphine sulfate intraveiously 27. The nurse is aware that which of the following clients is at greatest risk for developing medication toxicity? D) 73 year old diagnosed with hepatitis B - - Older adult require special consideration during medication administration. Some older adults have a greater sensitivity to drugs, especially those that act on the CNS. Brain receptors become more sensitive. Vascular nerve control is less stable. Liver mass shrinks. Metabolism drops to one-half to two third the rate of young adults. Drug half-life is prolonged. Gastric emptying rate slows. Lean body mass falls, adipose stores increase, and total body water declines, raising concentrations of water-soluble drugs. (715-716) 28. During admission interview a client adheres with the nurse that she is allergic to latex. The nurses immediate response is to: D) Place an identification bracelet on the client that identifies the latex allergy - - Patient with a known history of an allergy needs to avoid exposure and needs to wear an identification bracelet or medal which alters nurses and physicians to the allergy if the client is unconscious when receiving medical care (691) 29. To best prevent a systemic effect form a topically applied medication patch, the nurse must: B) Avoid applying medication to broken skin -- Systemic effects often occur if a clients skin in thin or broken down, if the medication concentration is high, or if contact with the skin is prolonged (695) 30. The nurse assigns ancillary personnel the task of giving a client a pre procedure enema. Which of the following statements made by the personnel requires immediate follow up by the nurse? The soapy water just came right back out - - may indicate obstruction (1199) 31. Research has shown that the primary reason nurses make medication errors is related to: Events that distract the nurse during administration process 32. 33. The home health nurse is preparing to educate a client on his or her newly prescribed medications. Which of the following nursing statements are appropriate to be included in this discussion? (Select all that apply): a. This medication is designed to lower your blood pressure c. The medication can make you dizzy especially if you stand up quickly d. What do you think will be the most difficult thing about taking this medication? e. You will need to take this medication once a day with breakfast seems to work best for most people


It is important that you dont miss taking the medication, if you do, take it when you remember but never take two

34. The school nurse suspects that a junior high student may have anorexia nervosa. This eating disorder is characterized by: B) Self-imposed starvation 35. The nurse should offer a client who has had throat surgery which of the following? B) Ginger ale 36. According to the food guide pyramid, vegetables should be included in the average adults diet as: C) 3-5 servings of vegetables should be consumed daily (1091 Food Guide Pyramid) 37. When assisting the client who practices Islam or Judaism with meal planning, the nurse knows that both religions share an avoidance of: D) Pork products (1096 table 44-3) 38. Which of the following would the nurse expect to see offered on a full liquid diet? A) Custard (1111 box 44-10) 39. 40. The client is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis identified for the client is feeding self-care deficit related to unilateral weakness. An appropriate technique for the nurse to use when assisting the client with feeding is to: Place food in the unaffected side of the mouth -- If the client has unilateral weakness, teach the client and caregiver to place food in the stronger side of the mouth (1111) 41. 42. One easy way that parents of teenagers can ensure that they are getting enough iodine in their diets to support the increased thyroid activity during adolescence is to: B) Use iodized table salt Iodine supports increased thyroid activity and use of iodized salt ensures availability (1093) 43. 44. Which of the following statements by a new mother indicates that the nurse needs to provide additional teaching before the client is discharged home with her infant? D) I can put a few drops of honey in my babys formula to make it taste better. 45. While doing a nutritional assessment of a low income family, the community health nurse determines the family diet is inadequate in protein content. The nurse suggests which of the following foods to increase protein content with little increase in the food budget? Peas and greens (1091)