Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is the amount of
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client
A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client’s skin turgor, the nurse should
A nurse is planning interventions for a group of
clients who are obese. What can the nurse do to
improve their commitment to a long term goal of weight loss?
When admitting a client, the nurse records which information in the client’s record first?
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Friction
reports severe pain.
grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back.
Attempt to develop the clients’ self-motivation.
Assessment of the client
1/27 5/25/2019
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A nurse tells a client that the provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following of the following is an appropriate nursing response?
A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood
pressure every 15 min. However, the machine is reading the client’s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?
A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self care and appropriately adds which of the following statements?
An assistive personnel (AP) says to the nurse, “This client is incontinent of stool three or four times a day. | get angry, and | think that the client is doing it just to get attention. | think we should put adult diapers on her.” Which is the appropriate nursing response?
A nurse’s neighbor is scheduled for elective surgery. The neighbor’s provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?
“Is there something about this procedure that concerns you?”
Disconnect the machine, and measure the blood pressure manually every 15 min.
“Tell me what | can do to help you overcome your fear of giving yourself injections.”
“It is very upsetting to see an adult client regress.”
Donating autologous blood before the surgery
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At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location?
A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially?
A nurse is caring for a client who requires rectal temperature monitoring. Available at the client’s bedside is a thermometer is with a long, slender tip. Which of the following is the appropriate action for the nurse to take?
A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the
A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is an nursing action?
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Second intercostal space to the right of the sternum.
Evaluate the pedal pulses.
Obtain a thermometer with a short, blunt insertion end.
involvement of the client in planning the change.
Firmly tell him to not grab
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An assistive personnel (AP) tells the nurse, “I am unable to find a large blood pressure cuff for a client who is obese. Can | just use the regular cuff if | can get it to stay on?” The nurse replies
that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is
Which of the following should the nurse do first when preparing to provide tracheostomy care?
A 3 year old child has had multiple tooth extractions while under general anesthesia. The client returns from the postanesthesia care crying, but awake, from the recovery room. Which approach is likely to be successful?
A nurse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. The client’s surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that
To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should
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high
Perform hand hygiene.
Examine the mouth last.
the signature on the preoperative consent form is the client’s.
place the bed in a high horizontal position.
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Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases?
When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of the following assessment findings prior to beginning chest compressions?
A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?
An older adult client appears agitated when the nurse requests that the client’s dentures be removed prior to surgery and states, “| never go anywhere without my teeth.” Which of the following is an appropriate nursing response?
To use the nursing process correctly, the nurse must first
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Elimination of the exposure
Absence of pulse
Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on the nurse’s shoulders, and the nurse’s hands under the client’s axillae.
“You seem worried. Are you concerned someone may see you without your teeth?”
obtain information about the client.
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A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client’s abdomen, the nurse expects the bowel sounds to be
While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?
A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included
A nurse is caring for a client diagnosed with a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to
When assessing a client’s heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a(n)
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Absent
Throw gloves away, perform hand hygiene
Cotton balls
encourage the client to express his thoughts about death and
dying.
pericardial friction rub.
