Exam 2 Flashcards
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. she states, “The client said his leg pain was back, so i checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PrN for pain, so i decided he needs it. i asked the unit nurse to observe me preparing and administering it. i checked with the client 40 minutes later, and he said his pain is going away.” The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process?
A.Assessment
B.Planning
C. intervention
D. evaluation
A. Assessment
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (select all that apply.)
A. respiratory rate is 22/min with even, unlabored respirations.
B.The client’s partner states, “He said he hurts after walking about 10 minutes.”
C.Pain rating is 3 on a scale of 0 to 10
D. skin is pink, warm, and dry.
E.The assistive personnel reports the client walked with a limp
A. respiratory rate is 22/min with even, unlabored respirations.
D. skin is pink, warm, and dry.
E.The assistive personnel reports the client walked with a limp
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
A. reassess the client to determine the reasons for inadequate pain relief.
B.Wait to see whether the pain lessens during the next 24 hr.
C. change the plan of care to provide different pain relief interventions.
D.Teach the client about the plan of care for managing his pain
A. reassess the client to determine the reasons for inadequate pain relief.
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (select all that apply.)
A.Writing a prescription for morphine sulfate as needed for pain.
B. inserting a nasogastric (Ng) tube to relieve gastric distention.
C. showing a client how to use progressive muscle relaxation.
D.Performing a daily bath after the evening meal.
E. repositioning a client every 2 hr to reduce pressure ulcer risk
C. showing a client how to use progressive muscle relaxation.
D.Performing a daily bath after the evening meal.
E. repositioning a client every 2 hr to reduce pressure ulcer risk
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process?
A.“i will determine the most important client problems that we should address.”
B.“i will review the past medical history on the client’s record to get more information.”
C.“i will go carry out the new prescriptions from the provider.”
D.“i will ask the client if his nausea has resolved
A.“i will determine the most important client problems that we should address.”
a nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. the client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for “real food.” the nurse tells the client that she will call the surgeon and ask. the surgeon hears the nurse’s report and prescribes a full liquid diet. the nurse used which of the following levels of critical thinking? A.Basic B.Commitment C.Complex D. integrity
A. Basic
a nurse receives a prescription for an antibiotic for a client who has cellulitis. the nurse checks the client’s medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate?
A.Fairness
B. responsibility
C. risk taking
D.Creativity
B. Responsibility
a nurse is caring for a client who is 24 hr postoperative following abdominal surgery. the nurse suspects the client’s pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply.)
A. the client seems easily agitated.
B. the client is nonadherent with coughing, deep breathing, and dangling.
C. the client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr.
D. the client reports tenderness in his right lower leg.
E. the client’s vital signs are heart rate 110/min, respiratory rate 20/min, temperature 37° C (98.6° F), and blood pressure 136/80 mm hg
B. the client is nonadherent with coughing, deep breathing, and dangling.
C. the client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr
E. the client’s vital signs are heart rate 110/min, respiratory rate 20/min, temperature 37° C (98.6° F), and blood pressure 136/80 mm hg
a nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. knowledge B. experience C. intuition D. Competence
A. Knowledge
a nurse uses a head‑to‑toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate?
A.Confidence
B.Perseverance
C. integrity
D. discipline
D. Discipline
a nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?
A. the client is able to discuss the appropriate technique.
B. the client is able to demonstrate the appropriate technique.
C. the client states that he understands.
D. the client is able to write the steps on a piece of paper
B. the client is able to demonstrate the appropriate technique.
a nurse in a provider’s office is collecting data from the mother of a 12‑month‑old infant. the client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. learning has occurred in which of the following domains?
A.Cognitive
B. affective
C.Psychomotor
D.Kinesthetic
B. Affective
a nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
A.“i don’t want my spouse to see my incision.”
B.“Will you give me pain medicine after the surgery?”
C.“Can you tell me about how long the surgery will take?”
D.“My roommate listens to everything i say.”
C.“Can you tell me about how long the surgery will take?”
a nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client?
A. encourage the client to participate actively in learning.
B.Select instructional materials appropriate for the older adult.
C. identify goals the nurse and the client agree are reasonable.
D. determine what the client knows about stress incontinence.
D. determine what the client knows about stress incontinence.
A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart‑healthy diet. the client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client’s learning?
A. encourage the client to ask questions.
B. ask the client to explain how to select or prepare meals.
C. encourage the client to fill out an evaluation form.
D. ask the client if she has resources for further instruction on this topic.
B. ask the client to explain how to select or prepare meals.
