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During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction B. Body C. Closing D. Orientation - A. Introduction Rationale: Asking about the weather initiates the social or introductory phase of the interview and ...

Which is the primary goal of community health nursing? A. To support and supplement the efforts of the medical profession in the promotion of health and prevention of B. To enhance the capacity of individuals, families and communities to cope with their health needs C. To increase the productiv...

Examples of primary prevention strategies include: a. colonoscopy at age 50 b. avoidance of tobacco products c. intake of a diet low in saturated fat in a patient with high cholesterol d. teaching the importance of exercise to a patient with hypertension - B - Primary prevention refers to measu...

In the United States, access to health care usually depends on a client's ability to pay for health care, either through insurance or by paying cash. The client the nurse is caring for needs a liver transplant to survive. This client has been out of work for several months and does not have insu...

the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. the nurse should be particularly alert to: A. Nasal congestion B. Abdominal Tenderness C. Muscle Tetany D. Oliguria - A. Nasal congestion why? removal of the pituitary gland is usua...

A nurse is reviewing a patient's medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? Note: More than one answer may be correct. A: Coumadin B: Finasteride C: Celebrex D: Catapress E: Habitrol F: Clofazimine - (A) and (B) a...

When selecting an NCLEX answer or determining the order of priority what should you remember or use and what is the exception? - Use the ABC rule: Airway breathing, and circulation. The exception to the rule is with actual CPR, use C-A-B for CPR. Also remember safety first and acute before chroni...

A client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the following referrals is appropriate for the nurse to make currently? 1. Physical Therapist 2. Speech Pathologist 3. Registered Dietitian 4. Occupational Therapist - 2. Speech Pathologist A clie...

A nurse is providing care based on Maslow's hierarchy of basic human needs. For which nursing activities is this approach useful? a. Making accurate nursing diagnoses b. Establishing priorities of care c. Communicating concerns more concisely d. Integrating science into nursing care - b. Maslo...

the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. the nurse should be particularly alert to: A. Nasal congestion B. Abdominal Tenderness C. Muscle Tetany D. Oliguria - A. Nasal congestion why? removal of the pituitary gland is usua...

Which is the primary goal of community health nursing? A. To support and supplement the efforts of the medical profession in the promotion of health and prevention of B. To enhance the capacity of individuals, families and communities to cope with their health needs C. To increase the productiv...

The parent of a preschooler with chickenpox asks the nurse about measures to make the child comfortable. The nurse instructs the parent to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder?...

After receiving report at the start of the evening shift, which of the following clients should the nurse attend to first? (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L. (b) A 21-year-old woman with sickle cell anemia with pain of 6 on a ...

The three components of the Intervention Wheel are: A) Communities, systems, and individuals/families. B) Interventions, color wedges, and levels of practice. C) Population base, levels of practice, and public health interventions. D) Populations at risk, populations of interest, and levels of p...

1. A nurse is asked about the goal of patient education. What is the nurse's best response? The goal of educating others is to help people a. Meet standards of the Nurse Practice Act. b. Achieve optimal levels of health. c. Become dependent on the health care team. d. Provide self-care only in...

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to bre...

D (Without understanding one's own beliefs and values, a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment values, beliefs, pra...

A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse supports the client's action, utilizing which ethical principle? 1. Beneficence 2. Veracity 3. Autonomy 4. Privacy - Answer...

When do *advanced directives* go into effect? - when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* - *coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; directives can always be changed later by person) SBAR Communication Framekwork Components - 1. *...

1. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which s...

The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding? 1. Increase in Forced Vital Capacity (FVC) 2. A narrowed chest cavity...

after listening to the parents reports and seeing the following pediatric clients, the nurse knows that which clent demonstrates signs of abuse that may need reporting 1. 1 year old with dyspnea, drooling, and a swollen tongue after eating part of houseplant 2. 2 year old who is crying and has la...

The nurse on a locked psychiatric unit is administering morning medications to a patient with schizophrenia. The patient refuses and says, "I'm not going to take that!" What is the nurse's BEST response? 1. "You have the right to refuse this medication, but the doctor may get a second opinio...

A registered nurse arrives at work and is told to "float" to the ICU for the day because the ICU is understaffed and needs an additional nurse to care for the clients. The nurse has never worked in the ICU. Which of the following is the most appropriate nursing action? A. refuse to float in the...

A nurse informs the patient's health care provider that the patient is refusing potentially life saving surgery. In this situation, which ethical principle is the nurse using? Beneficence Nonmaleficence Autonomy Justice - Autonomy Using the principle of autonomy allows individuals to have the...

Which of the following are examples of medical battery? Select all that apply. 1. A child is placed in a papoose restraint for suturing of a facial laceration with the parent present 2. Application of soft wrist restraints to the arms of a confused, adult client with a NG tube 3. The nurse admini...

Which would the nurse Not list as a purpose of the nursing code of ethics when discussing it with a group of new employees? 1. Reminding nurses of the special responsibility they assume when caring for the sick 2. Guiding the profession in self-regulation 3. Providing solutions for specific ethi...

Low-residue diet - Dairy products & eggs, such as custard and yogurt (Rat) A low-residue diet consists of foods that are low in fiber and are easy to digest such as eggs, custard, yogurt and ripe bananas - NOTE Legumes such as lentils and black beans are high in fiber and are not considered low i...

The nurse teaches the client that the major difference between angina and pain associated with myocardial infarction (MI) is that: A) Angina is relieved with nitroglycerin and rest. B) Angina can be fatal. C) MI pain always radiates to the left arm or jaw. D) MI pain cannot be treated. - A) Ang...

It will be most important for the nurse to check pulse oximetry for which of these patients? a. A patient with emphysema and a respiratory rate of 16 b. A patient with massive obesity who is refusing to get out of bed c. A patient with pneumonia who has just been admitted to the unit d. A patien...

For a patient prescribed hydrochlorothiazide (HydroDIURIL), the nurse should closely monitor which laboratory test value? A. Sodium B. Glucose C. Calcium D. Chloride - B. Glucose Correct Thiazide and thiazide-like diuretics are associated with adverse metabolic effects of hyperglycemia; there...

A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? 1) Phantom 2) Visceral 3) Deep somatic 4) Referred - Answer: 3) Deep somatic Rationale: Deep somatic p...

1.The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be prepared for which maternal adverse reactions? Select all that apply: 1. Hypertension 2. Jaundice 3. Dehydration 4. Fluid overload 5. Uterine tetany 6. Bradycardia - 1, 4, 5 2. A clie...

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 2. To contact the surgeon if eye scratchiness o...

1. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. 1. Partial thromboplastin time. 2. Prothrombin time. 3. Platelet count. 4. Hemoglobin 5. Complete Blood Count 6. White Blood Cell Count ...

A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to ...

When selecting an NCLEX answer or determining the order of priority what should you remember or use and what is the exception? - Use the ABC rule: Airway breathing, and circulation. The exception to the rule is with actual CPR, use C-A-B for CPR. Also remember safety first and acute before chroni...

A nurse is providing care based on Maslow's hierarchy of basic human needs. For which nursing activities is this approach useful? a. Making accurate nursing diagnoses b. Establishing priorities of care c. Communicating concerns more concisely d. Integrating science into nursing care - b. Maslo...

A client has a continuously running peripheral infusion. The physician orders an antibiotic as a piggyback infusion four times per day. In order to administer the antibiotic, the nurse should do which of the following? Select all that apply. 1. Avoid compatibility issues by starting an additional...

which of the following interventions are a priority during exacerbation of left sided HF - high fowlers, O2, diuretics The nurse is preparing a pt to be discharged after a diagnosis of HF. which statement shows an appropriated understanding of nurses teachin - -I will call doc if I gain more than...

Prep U Chapter 63 Eye & Vision Disorders Med-Surg, Extra Eye Questions NUR 170: M3 Eye disorders NCLEX practice exam, NCLEX Eye Disorders, NCLEX cataract & glaucoma Which of the following terms refers to the absence of the natural lens? A)Aphakia B)Scotoma C)Keratoconus D)Hyphema - A)Aphaki...

A nurse is caring for a client who ingested a toxic amount of acetaminophen 36 hr ago. For which of the following findings should the nurse monitor? Select all that apply a. elevated troponin level b. diaphoresis c. hyperglycemia d. abdominal discomfort e. increased alanine aminotransferase (A...

The nurse explains to the patient with gastroesophageal reflux disease that this disorder: A. results in acid erosion and ulceration of the esophagus caused by frequent vomiting, B. will require surgical wrapping or repair of the pyloric sphincter to control the symptoms, C. is the protrusion of ...

1. The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? 1. "How much weight have you gained recently?" 2. "What have you done to alleviate your heartburn?" 3. "Do you consume many milk and dairy pro...

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? a) "I swim three times a week." b) "I have stopped smoking cigars." c) "I drink ho...

1. To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. the presence of blood in the urine. b. any erectile dysfunction (ED). c. occurrence of a weak urinary stream. d. lower back and hip pain. - Answer: C Rati...

Which of these conditions may cause the fetal heart rate to be lower during labor? (Choose all that apply.) A. Stimulation of the sympathetic nervous system B. Stimulation of the baroreceptors, which in turn stimulates the vagus nerve C. Prolonged hypoxia, hypercapnia, and acidosis D. Stimulati...

The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client's cardiac monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus. - The nurse should suspect Your Answer: hypokalemiaCorrect...