Nursing Care Flashcards
The nurse is preparing a client to treat macrocytic anaemia. Which is the nurse’s priority intervention?
A. Administer the prescribed vitamin supplement.
B. Obtain a focused nutritional assessment.
C. Obtain a consultation with the nutritionist.
D. Review the laboratory results for baseline.
D. Review the laboratory results for baseline.
The nurse is preparing to define quality in healthcare for a nursing student. Which statement should the nurse include?
A. “Quality refers to reducing the cost of healthcare for the client.”
B. “Quality refers to protecting clients from risk and harm while they are receiving care.”
C. “Quality refers to a nurse integrating morals and values into client care.”
D. “Quality refers to how well health services achieve the desired outcomes for a client or population.”
D. “Quality refers to how well health services achieve the desired outcomes for a client or population.”
The nurse is creating a care plan for an 88-year-old female client on a medical unit for a urinary tract infection (UTI). Which intervention(s) should the nurse include? Select all that apply.
A. Instruct the health assistant to strain all urine
B. Communicate with the provider if the client becomes confused
C. Offer toileting with each client encounter
D. Put “high fall risk” signage on the client’s door
E. Communicate with the health assistant to record intake and output once per day
B. Communicate with the provider if the client becomes confused
C. Offer toileting with each client encounter
D. Put “high fall risk” signage on the client’s door
The nurse is caring for a 95-year-old client with dementia and multiple pressure injuries of advanced stage. The client is being treated for sepsis related to her infected wounds. Which consult(s) should the nurse expect for this client? Select all that apply.
A. Psychiatry
B. Wound Care
C. Infectious Disease
D. Surgery
E. Nutrition
B. Wound Care
C. Infectious Disease
D. Surgery
E. Nutrition
The nurse has chosen a quantitative research design for their study. Which information is correct regarding this design method? Select all that apply.
A. Quantitative research is used to answer more “what is” types of questions.
B. Data for a quantitative research design comes from a formal experiment.
C. Quantitative research aims to find the cause and effect relationship.
D. Quantitative research designs are systematic and objective.
E. Quantitative research shows a relationship between two or more variables.
F. Quantitative research designs are used to understand more about a population.
A. Quantitative research is used to answer more “what is” types of questions.
B. Data for a quantitative research design comes from a formal experiment.
C. Quantitative research aims to find the cause and effect relationship.
D. Quantitative research designs are systematic and objective.
E. Quantitative research shows a relationship between two or more variables.
The nurse educator is preparing a presentation on the use of SBAR to improve the quality and safety of clients on the unit. When using the SBAR tool, the following “what led to the current situation,” is an example of which part of SBAR?
Background
The nurse educator is preparing a presentation on the use of SBAR to improve the quality and safety of clients on the unit. When using the SBAR tool, the following “the nurse will provide a potential solution,” is an example of which part of SBAR?
Recommendation
The post-anaesthesia care nurse has received a client from the operating room in the unit (PACU). Which activities should the nurse anticipate performing? Select all that apply.
A. Assess respiratory status
B. Perform surgical instrument counts
C. Assess Pain
D. Cardiovascular Assessment
E. Assess Urinary output
F. Obtaining surgical consent
G. Assess Level of Consciousness (LOC)
H. Assess temperature
A. Assess respiratory status
C. Assess Pain
D. Cardiovascular Assessment
E. Assess Urinary output
G. Assess Level of Consciousness (LOC)
H. Assess temperature
The nurse is creating a plan of care for a client with coronary artery disease (CAD) experiencing chronic stable angina. The client has a history of smoking, hypertension, and hyperlipidaemia. Which nursing diagnosis is the highest priority?
A. Ineffective health maintenance related to hyperlipidaemia
B. Decreased cardiac tissue perfusion related to coronary artery disease
C. Deficient knowledge related to lack of information regarding CAD
D. Risk for decreased cardiac output related to hyperlipidaemia
B. Decreased cardiac tissue perfusion related to coronary artery disease
A pediatric client presents to the emergency department in no acute distress for a scaling rash with a gray coating and fever. After a nurse triages this client, what is the next most appropriate action?
A. Report the case to the board of health
B. Prepare for endotracheal intubation
C. Administer a dose of acetaminophen
D. Move the client to a private room
D. Move the client to a private room
This client has signs of diphtheria, a contagious disease. The nurse should move this client to a private room and be sure to don appropriate personal protective equipment (PPE) before further assessment or intervention in case the client has diphtheria.
An experienced behavioral health nurse and psychiatrist are part of the care team for a client with bulimia nervosa. Which intervention is an appropriate task for the nurse to perform?
A. Diagnose the client with adjustment disorder
B. Add goals to the client’s plan of care
C. Prescribe mood stabilizing medications
D. Renew an order for constant observation
B. Add goals to the client’s plan of care
The nurse reviews a list of pediatric clients scheduled to be seen in the clinic. Which client has the highest risk of contracting impetigo?
A. A 12-year-old presenting for a physical exam before attending an overnight camp.
B. A two-month-old infant diagnosed with croup is cared for at home.
C. An 18-month-old who requires immunizations before traveling out of the country.
D. A three-year-old presenting for a routine physical who attends day-care.
D. A three-year-old presenting for a routine physical who attends day-care.
A three-year-old child who attends day-care has the highest risk of contracting impetigo because it is commonly spread in a day-care setting.
Which nursing diagnosis is most important to prioritize for a client diagnosed with a pressure injury?
A. Risk for electrolyte imbalance
B. Disturbed body image
C. Risk for infection
D. Disturbed sleep pattern
C. Risk for infection
Which nursing diagnosis is the nurse’s priority when caring for a small child diagnosed with epiglottitis?
A. Risk for deficient fluid volume related to decreased intake, fever, and increased work of breathing
B. Compromised parental coping related to sudden onset of child’s acute illness
C. Ineffective airway clearance related to airway inflammation
D. Anxiety related to sudden onset of acute illness
C. Ineffective airway clearance related to airway inflammation
Using the prioritization model of airway, breathing, circulation (ABC), protecting and maintaining clients’ airways is the main concern.
Which assessment(s) is/are most important to include in the documentation for a client diagnosed with pulmonary embolism (PE)? Select all that apply.
A. Frequency and amount of alcohol use
B. Cardiovascular assessment
C. Recent surgical history
D. Presence of adventitious breath sounds
E. Use of assistive devices
F. History of anticoagulant use
B. Cardiovascular assessment
C. Recent surgical history
D. Presence of adventitious breath sounds
F. History of anticoagulant use
A nurse in the post-anesthesia care unit is caring for a 4-year-old child post-tonsillectomy. The child is crying, and the caregiver at the bedside refuses to hold the child, yelling at them to quiet down. After physical assessment of the client, the nurse notes multiple bruises in various stages of healing, on the face and abdomen. What initial action should the nurse take?
A. Obtain an order for patient-controlled anaesthesia (PCA)
B. Instruct the caregiver to wait in the waiting area until the child is calm
C. Notify the attending surgeon who performed the tonsillectomy
D. Report the incident to their direct supervisor
B. Instruct the caregiver to wait in the waiting area until the child is calm
When child abuse is suspected, the first thing the nurse should do is ensure a safe environment for the child. This may include separating the child from the abuser. In this case, instructing the caregiver to wait until the child is more calm may allow the nurse to comfort the child and report the incident to the proper authority.
A new graduate nurse is caring for a client preparing to undergo a subtotal colectomy. The surgeon asks the nurse to assist with obtaining informed consent. Which action by the nurse is most appropriate?
A. Confirming the client understands the information provided
B. Obtaining telephone consent without another nurse present
C. Explaining the procedure to the client
D. Telling the client about the risks of the procedure
A. Confirming the client understands the information provided
The nurse’s main role in obtaining informed consent is to “witness” the consent, which means that the nurse is confirming that the correct client is actually signing the consent at the date and time specified.
The nurse is caring for a client who had an emergency caesarean section for a prolapsed umbilical cord. Which information should the nurse include regarding the early recovery period for the post-caesarean teaching plan?
A. Pain management
B. Dietary restrictions
C. Strict bed rest
D. Delayed breastfeeding
A. Pain management
The nurse has admitted a client to the hospital with primary progressive multiple sclerosis. Which is the nurse’s priority intervention?
A. Prepare the client for plasmapheresis.
B. Implement fall precautions.
C. Obtain a physical therapy consultation.
D. Monitor intake and output.
B. Implement fall precautions.
An experienced nurse on a medical surgical unit is aware that new research states there is no benefit to rotating intravenous access sites to reduce phlebitis in hospitalized patients. The nurse overhears a new graduate nurse telling a client that they are planning to insert another intravenous line in order to rotate the site. What is the most appropriate action for the experienced nurse to take?
A. Remind the new nurse that research findings should always be applied to practice
B. Teach the new nurse how to insert a peripheral intravenous line
C. Tell the new nurse that rotating the access site would cause the client harm
D. Ask the new nurse what they understand about the evidence for rotating sites
D. Ask the new nurse what they understand about the evidence for rotating sites
The nurse is performing the assessment of a client diagnosed with leukemia. Which assessment finding should the nurse report to the primary healthcare provider immediately?
A. Heart rate 90/min and pale skin
B. Weight gain of one pound in one week
C. Blood pressure 116/80 mmHg
D. New onset of crackles at the base of the lung
D. New onset of crackles at the base of the lung
A new onset of crackles at the base of the lungs indicates infection in the lungs. Clients with leukaemia are at an increased risk of respiratory, urinary, or integumentary infections due to the reduction of functional white blood cells
The public health nurse is reviewing the schedule of client appointments for the day. The nurse knows there has been a recent outbreak of influenza in the community. Which client is most at risk for developing influenza?
A. A 60-year-old who was recently had a flu vaccine
B. An 80-year-old nursing home resident
C. A 45-year-old client with peripheral neuropathy
D. An 8-year-old client who attends school virtually
B. An 80-year-old nursing home resident
A male client presenting with urethral discharge and dysuria tests positive for chlamydia and gonorrhea. Which is the priority nursing diagnosis for this client?
A. Deficient knowledge related to chlamydia treatment and prevention
B. Acute pain related to urethritis
C. Impaired urinary elimination related to urethritis
D. Infection related to unsafe sexual practices
C. Impaired urinary elimination related to urethritis
Impaired urinary elimination related to urethritis is the priority nursing diagnosis. A client with impaired urinary elimination is at risk for injury to the bladder and infection.
The nurse is working on a quality improvement committee to improve client safety. What statement does the nurse recognize as the best definition of safety?
A. “Safety refers to protecting clients from risk and harm while they are receiving care.”
B. “Safety refers to doing the right thing for the client.”
C. “Safety refers to upholding the healthcare organizations policies.”
D. “Safety refers to the nurse practicing within the scope of their practice.”
A. “Safety refers to protecting clients from risk and harm while they are receiving care.”
The nurse manager is preparing to implement self-scheduling in the unit. Which action by the nurse manager reflects a democratic style of leadership?
A. Inform the staff that they can get together to decide whether they would like to pursue the change.
B. Provide the staff education about the plan for rolling out the change in scheduling.
C. Schedule a time to meet with the staff to discuss the proposed change and encourage them to help decide how the change will be implemented.
D. Inform the nursing staff when the exact changes and when they will be implemented.
C. Schedule a time to meet with the staff to discuss the proposed change and encourage them to help decide how the change will be implemented.
The post anesthesia care unit (PACU) nurse is caring for a client who underwent a radical mastectomy of the left breast. Which finding should the nurse immediately report to the healthcare provider?
A. Small amount of serosanguineous drainage on dressing
B. Oxygen saturation 97% on room air
C. Blood pressure 122/78 mmHg
D. Unequal bilateral arm circumference
D. Unequal bilateral arm circumference
Bilateral arm circumference should be equal. An increase in arm circumference in the arm of the affected breast may indicate that clients are experiencing lymphedema.
The nurse is preparing to assess a male client diagnosed with gonorrhea and chlamydia. Which clinical finding should the nurse immediately report to the healthcare provider?
A. Testicular swelling
B. Inability to void
C. Testicular pain
D. Mucopurulent penile discharge
B. Inability to void
Chlamydia and gonorrhoea can infect the urethral mucosa, causing inflammation known as urethritis. The inflammation can block the flow of urine, causing urinary retention, infection, and increasing the risk for injury to the bladder.
A nurse in the emergency department triages a 75-year-old client with advanced pancreatic cancer. The client was brought to the emergency department by the client’s husband because the client has been experiencing increasing weakness in the lower extremities. The client’s husband tells the nurse that the client was put on hospice care two weeks ago. Which question is most appropriate for the nurse to ask the client’s husband next?
A. “How many months left does the client have left to live?”
B. “Can you tell me what you understand about hospice care?”
C. “What is the client’s baseline mental status?”
D. “Does the client’s skin color appear more yellow to you than normal?”
B. “Can you tell me what you understand about hospice care?”
The nurse is preparing an interdisciplinary plan of care for a client diagnosed with a myocardial infarction (MI). Which is an appropriate task to delegate to a Health Assistant?
A. Performing a pain assessment
B. Obtaining blood pressure and pulse
C. Administer fluids through an intravenous (IV) line
D. Teaching the client about low sodium food choices
B. Obtaining blood pressure and pulse
Josie, a 38 year old woman is admitted to the emergency room after being found unconscious at the wheel of her car in the hospital car park. Josie is comatose and does not respond to stimuli. A drug overdose is suspected
Which of the following assessment findings would lead the nurse to suspect that the coma is a result of a toxic drug overdose
A. Hypertension
B. Hyperpyrexia
C. Dilated pupils
D. Facial asymmetry
B. Hyperpyrexia
