Test 4 Review Quiz Flashcards
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?
A - to the nondominant side of the client, with legs together and one foot near the head of the bed.
B - near the client’s hip, with legs together
C - to the dominant side of the client, with legs together and one foot near the head of the bed
D - near the client’s hip, with legs shoulder width apart and one foot near the head of the bed
D - near the client’s hip, with legs shoulder width apart and one foot near the head of the bed
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:
A - alcohol use.
B - croup.
C - asthma.
D - pneumonia.
D - pneumonia.
Which group of terms best defines assessing in the nursing process?
A - Collection, validation, communication of client data
B - Problem-focused, time-lapsed, emergency-based
C - Nurse-focused, establishing nursing goals
D - Designing a plan of care, implementing nursing interventions
A - Collection, validation, communication of client data
An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?
A - Healthcare-associated infection
B - Sexually transmitted infection
C - Respiratory infection
D - Droplet infection
A - Healthcare-associated infection
A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.
A - distended neck veins
B - poor skin turgor
C - crackles in the lungs
D - blood pressure 100/48 mm Hg
E - excessive urination
A - distended neck veins
C - crackles in the lungs
The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states:
A - “I do not need to wash my hands if I am using gloves.”
B - “I can wash my hands before a clean procedure.”
C - “I will wash my hands before touching a client.”
D - “If I am able, I will wash my hands after touching the client’s surroundings.”
A - “I do not need to wash my hands if I am using gloves.”
A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?
A - The nurse evaluates the plan of care.
B - The nurse evaluates the client’s goal/outcome achievement.
C - The nurse evaluates the competence of nurse practitioners.
D - The nurse evaluates the types of health care services available to the client.
B - The nurse evaluates the client’s goal/outcome achievement.
A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which sign(s) is observed? Select all that apply.
A - The client demonstrates restlessness.
B - The client’s capillary refill is assessed at 4 seconds.
C - The client has uneven movements of the chest with respirations.
D - The client has a respiratory rate of 16 breaths/min.
E - The client has flaring nostrils.
A - The client demonstrates restlessness.
B - The client’s capillary refill is assessed at 4 seconds.
C - The client has uneven movements of the chest with respirations.
E - The client has flaring nostrils.
In which client should the nurse prioritize assessments for respiratory depression?
A - A client taking opioids for cancer pain
B - A client taking insulin for type 1 diabetes
C - A client taking antibiotics for a urinary tract infection
D - A client taking a beta-adrenergic blocker for hypertension
A - A client taking opioids for cancer pain
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
A - Clean the wound from the top to the bottom and from the center to outside.
B - Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.
C - Use clean technique to clean the wound.
D - Clean the wound in a circular pattern, beginning on the perimeter of the wound.
A - Clean the wound from the top to the bottom and from the center to outside.
A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply.
A - encourage the client to take fluids every 2 hours
B - elevate the head of the bed 90 degrees four times daily
C - pull the client up in bed as needed
D - turn the client every 2 hours when the client is in bed
E - provide incontinent care every 2 hours and as needed
A - encourage the client to take fluids every 2 hours
D - turn the client every 2 hours when the client is in bed
E - provide incontinent care every 2 hours and as needed
Which nursing action associated with successful tube feedings follows recommended guidelines?
A - Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract.
B - Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid.
C - Prevent contamination during enteral feedings by using an open system.
D - Check the residual before each feeding or every 4 to 6 hours during a continuous feeding.
D - Check the residual before each feeding or every 4 to 6 hours during a continuous feeding.
A nurse is caring for a client with a diagnosis of metastatic lung cancer. The nurse finds the client sitting in a chair while staring out the window. What statement by the nurse communicates concern and caring about the client?
A - “You are going to be okay. Your doctor is one of the best cancer specialists and knows the best way to treat your cancer.”
B - “I think you should talk to your friends and family, getting their help and support will make you feel better.”
C - “I can imagine you have many concerns about your health. Tell me what is on your mind.”
D - “Don’t worry. There are all kinds of cancer treatments available. You will be just fine.”
C - “I can imagine you have many concerns about your health. Tell me what is on your mind.”
During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?
A - deep breathing
B - diaphragmatic breathing
C - pursed-lip breathing
D - incentive spirometry
A - deep breathing
The primary purpose for evaluating data about a client’s care according to a functional health approach is to:
A - determine implementation of medical orders.
B - revise or modify the client care plan.
C - meet accreditation standards.
D - evaluate the need for health care consultations.
B - revise or modify the client care plan.
