Holsitic Final Exam

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI) for the fourth time in 4 years. The nurse plans to address the potential concern for the client's risk-prone behavior. What assumption prompted the nurse to address this concern?

Having multiple STIs over multiple years means the client is sexually active.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

• a cognitive outcome.

Which action should the nurse perform during the planning step of the nursing process?

• Selects nursing measures, including client education

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment?

• Client is unable to communicate basic needs and cannot perform hygiene measures with left hand.

During the health education session at the health care facility, the nurse notes that a client is able to recognize, describe to others, and explain the information learned. What is the final learning stage of the client in this case?

• Independent use of new learning

Which nursing intervention is an example of tertiary preventive care?

• Assisting with speech therapy a client with a traumatic brain injury

Which charting format permits documentation on any significant topic, not just client problems?

FOCUS

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the “S” information?

• Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR

The nurse attempts to notify a health care provider about a client’s elevated temperature but does not get a response. Which statement, if documented by the nurse, would indicate that the nurse is following proper protocol for nursing documentation?

• 1300: Client temperature elevated. Telephoned health care provider's service 3 times without a response. Tepid sponge bath given and nursing supervisor notified.

The nurse is teaching a client how to take medications upon discharge. The client is alert and oriented but unable to articulate the teaching back to the nurse. What is the appropriate nursing action?

• Give written instructions to the client and caregivers.

A nurse working at the clinic is providing care to several children of various ages. Which child would the nurse expect to see experiencing the greatest development in speech?

• 4-year-old child

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

• uses broad, open statements to communicate with the client.

The nurse is teaching the parents of an adolescent about safety. Which teaching will the nurse include?

• Be alert for signs of peer pressure.

The school nurse is providing education on poisoning risks to adolescent students. Which topic does the nurse include in the teaching?

• experimentation with drugs and inhalants

When moving a client up in bed with the assistance of another caregiver, the nurse should:

• have the client fold the arms across the chest.

Which nurse would be at the highest risk of causing a hazardous situation?

• A nurse who has worked 32 hours of overtime this week

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

• the public health department

The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response?

• encourage the colleague to remove the glove by grasping the cuff

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

• A client who has leg strength and can cooperate with the movement

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

• WBC of 25,000 mcL

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in the body's response to infection?

• Migration of leukocytes to the area of the wound

The school nurse performs frequent assessments of young school-aged children. Due to their high incidence and prevalence, the nurse should prioritize assessment for what type of infections?

respiratory

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

• Use a sterile cotton-tipped applicator to apply the prescription to the site

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?

handwashing

A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

• helps to determine prescribed antibiotic therapy

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator?

• “Wearing an N95 respirator is critical when I care for clients in droplet precautions.”

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

• Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

A health care provider at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler?

• a canister containing medication that is released when the container is compressed

The nurse has administered a glycerin suppository to a client who has not had a bowel movement for several days. One minute after the nurse inserted the suppository, the client told the nurse that they involuntarily expelled the suppository. What is the nurse's best action?

• Apply more lubricant to the suppository and reinsert it.

The nurse is preparing to administer a bolus of an intravenous medication. How should the medication be administered?

All at once

After teaching a group of nursing students about pharmacokinetics, the instructor determines that the education was successful when the students identify what process by which the medication is delivered to the target cells and tissues?

Distribution

A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube?

• Avoid crushing sustained-release pellets.

An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method?

• self-contained packets that hold one tablet or capsule for individual clients

A nurse needs to instill eye medication in a client with conjunctivitis. Which action is best to distribute the medication over the surface of the eye?

• The client should blink the eye.

A young client has an IV infusing for magnesium sulfate to treat preterm labor. The client develops a fever. What is the first assessment the nurse should make?

• Assess the IV site for redness.

The nurse is preparing to administer an IM injection in the vastus lateralis site. Where will the nurse administer the medication?

• in the anterolateral aspect of the thigh

The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe?

• decreased irritation and pain in subcutaneous tissue

A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration?

Deltoid

The health care provider has prescribed warfarin 11.25 mg daily. The pharmacy has sent warfarin 7.5 mg in scored tablets. Which action should the nurse take?

• Divide one tablet into two and administer 1.5 tablets.

The nurse is preparing to give a vaccination to an infant. At which site should the nurse plan to administer the injection?

• vastus lateralis

A nurse needs to administer an intramuscular injection to a client. The site that the nurse has chosen contains the sciatic nerve. Which action should the nurse perform first to locate the appropriate landmarks and avoid damaging the sciatic nerve?

• Divide the buttock into four imaginary quadrants.

Which nursing strategy should the nurse employ to assist a child who has difficulty coordinating inspiration with the use of a handheld inhaler?

• The nurse should use a nebulizer to administer the medication.

The nurse correlates the metric system as the most accurate method utilized to administer medications for which reason?

• The dosage prescriptions of medications most often use this system as it is measured in 10s and can be easily converted between measurements

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle collision. The health care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

• Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

• a surgical incision with sutured approximated edges

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?

• Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

• To splint the area when engaging in activity

The nurse is teaching a client about wound care at home following a cesarean birth of their infant. Which client statement requires further nursing teaching?

• “Reinforced adhesive skin closures will hold my wound together until it heals.”

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports “it feels numb.” What is the best action by the nurse at this time?

• Discontinue the therapy and assess the client.

A child is brought to the clinic by a parent who states that the child has been at camp. The child has a rash on the face, arms, and legs and says that it itches severely. How will the nurse document the assessment findings?

• Diffuse dermatitis accompanied by pruritus.

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?

distilled water

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

• Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.

The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize?

• flow meter set at 5 liters of oxygen

A parent brings their 2-year-old child to the emergency department in respiratory distress. The child's oxygen saturation is 81%, and there is audible stridor. What intervention will the nurse anticipate?

• placement in an oxygen tent

The unlicensed assistive personnel (UAP) is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

• "You are free to move onto the stretcher without assistance, but I will supervise for your safety."

An athlete wants to increase their intake of complex carbohydrates and asks the nurse about potential sources. Which food is considered a complex carbohydrate?

Potatoes

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?

Vitamin K

A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client’s level of malnutrition?

Serum Albumin levels

A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client’s level of malnutrition?

• Try eating foods that are attractive and at the proper temperature.

The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition?

Iodine deficiency

A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate?

• vegetable plate for a client who practice Hinduism

Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor?

• “According to research, vegetarians have a higher incidence of obesity than others.”

A client who is vegetarian talks with the nurse about eating complementary proteins. Which combination of foods will the nurse identify that complement each other?

• navy beans and whole wheat bread

A nurse is planning a high-energy diet for a client. Which statement by the nurse best describes the types of foods the client should include in the diet?

• “Include plenty of grains, fruits, and vegetables in your diet.”

A client has been diagnosed with a deficiency in a fat-soluble vitamin. Which vitamin supplement is most likely to benefit the client?

Vitamin E

Prior to allowing a client to eat, which action is most important for the nurse to take?

• Assess the client’s level of consciousness.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

• a referral.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

• a client who is homebound and needs skilled nursing care