Test 2 Flashcards
Which is the most important nursing action involved in caring for a client receiving medications?
a.) administering the medications
b.) teaching about the medications
c.) ensuring adherence to the medication regimen
d.) evaluating the client’s ability to self-administer medications
a
Which example illustrates health promotion activities? SATA
a.) good nutrition
b.) regular exercise
c.) physical awareness
d.) immunization against measles
e.) education about stress management
a and b
Which action would the nurse take when a client is receiving total parenteral nutrition (TPN)? SATA
a.) monitor for hydration
b.) monitor weight daily
c.) monitor vital signs every 4 hours
d.) discard any solution after 24 hours
e.) check the expiration date of the solution before administration
all
After assessing several clients, the nurse would determine which client will require parenteral nutrition?
a.) a client with brain neoplasm
b.) a client with anorexia nerosa
c.) a client with inflammatory bowl disease
d.) a client with severe malabsorption disorder
d
A hospitalized client experiences a fall after climbing over the bed’s side rails. Upon reviewing the client’s medical record, the nurse discovered that restraints had been prescribed but were not in place during the fall. Which information would the nurse include in the follow-up incident report?
a.) a statement that the nursing staff was not at fault because the client initiated the accident
b.) a listing of facts related to the incident as witnessed by the nurse
c.) the name of the nurse responsible for implementing the restraints
d.) the potential reasons why the restraints were not in place at the time of the fall
b
Which instructions to minimize the risk of falls in the home the nurse provide the caregiver of an older client who requires the use of a walker with wheels? SATA
a.) remove cords
b.) apply bed alarms
c.) use bright lighting
d.) get rid of throw rugs
e.) keep phone close by
a, c, and d
After a home assessment of an older adult’s fall risk, which intervention would the nurse suggest? SATA
a.) dimming lighting to avoid squinting
b.) secure rugs to prevent movemement
c.) remove excessive pieces of furniture
d.) wear corrective lenses for distance vision
e.) perform exercises to strengthen lower extremities
b, c, d, and e
Which risk factor(s) regarding fall prevention and safety for older adults would the nurse manager include in a presentation to a group of nurses? SATA
a.) medications
b.) visual changes
c.) urinary retention
d.) decreased appetitie
e.) orthostatic hypotension
a, b, and e
After presenting information about falls risk assessments to nursing staff, which participant’s statement needs review for corrective action?
a.) “we will assess every admission to the unit”
b.) “we will implement a valid falls risk assessment tool”
c.) “we will apply yellow wrist bands to high-risk clients”
d.) “we will use the admission fall assessment for the entire stay”
d
The nurse is transferring a client from the bed to the chair. Which action would the nurse take first during the transfer?
a.) place the client in a semi-fowler position
b.) stand behind the client during the transfer
c.) turn the chair so it faces the bed
d.) instruct the client to dangle the legs
d
Which intervention would prevent urinary stasis and formation of renal calculi in an immobile client/
a.) increasing oral fluid intake to 2 to 3 L/day
b.) maintaining bed rest after discharge
c.) limiting fluid intake to 1 L/day
d.) voiding at least every hour
a
Which complication would the nurse monitor for in a client on strict bed rest for 3 days?
a.) atelectasis
b.) hypotension
c.) constipation
d.) pressure injuries
e.) urinary tract infections
all
The nurse finds that a visually impaired client is having difficulty in determining which medications to take after being discharged from the hospital. Which intervention would be best in this situation?
a.) filling and labeling the medication bottles for the client
b.) advising the caregiver to administer the client’s medication
c.) recommending that the client’s pharmacy relabel the medication in large letters
d.) showing the client examples of pill organizers that will help the client sort the medication
c
The nurse administers an older adult client’s medications via a gastrostomy tube in the long-term care setting. Which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? SATA
a.) absence of bowel sounds
b.) presence of abdominal distention
c.) residual capacity exceeding 300mL
d.) positive guaiac test of abdominal contents
e.) seepage of feeding around the trachesotomy
all
Which findings noted during assessment would lead the nurse to determine that a client is at an increased risk for infection? SATA
a.) surgical incision
b.) urinary catheter
c.) antibiotic therapy
d.) intravenous access
e.) diminished appetite
a, b, c, and d
