An 18 year old woman is in the emergency C
department with fever and cough. The nurse
obtains her vitals, listens to her lung and
heart sounds, determines her level of
comfort, and collects blood and sputum
samples for analysis. which standard of
practice is performed?
a. diagnosis
b. evaluation
c. assessment
d. implementation
An adult male client with a history of A
hypertension tells the nurse that he is tired
of taking antihypertensive medications and the prolonged practice of meditation may lead to a reduced need for
is going to try spiritual meditation instead. antihypertensive medications. However, the medications must be continued while the
What should be the nurse's first response? physiologic response to meditation is monitored.
a. "it is important that you continue your
medication while learning to meditate."
b. "spiritual meditation requires a time
commitment of 15 to 20 minutes daily."
c. "obtain your healthcare provider's
permission before starting meditation."
d. "complementary therapy and western
medicine can be effective for you."
,after a recent total hip replacement, an D
older female client, who transferred into a
rehab facility placement, asks the RN if she the best response provides the client with an explanation based on aging and
broke her hip because she is old. How demineralization of the bone in older females especially after menopause
should the RN best respond?
a. hip fractures can occur in any age group
and require strength conditioning
b. with aging, everything tends to break
down more easily the older one gets
c. older people tend to look down instead
of ahead, increasing the risk of falls
d. older women commonly lose bone
calcium which increases the risk of fracture
after a transurethral resection of the A
prostate, an older man returns to the
medical surgical floor with 3-way cath. The the feeling of urgency can be caused by blood clots that can occult the drainage of
RN observes the cath's tubing for drainage the cath, which is common occurrence in the first 72 hours after TURP.
when the client states that he needs to void.
What should the RN implement based on
this finding?
a. irrigate the bladder though the cath port
b. remove cath
c. explain that urgency is expected
d. notify healthcare provider of the
symptom
, After taking a 10-day course of an antibiotic B
that was ineffective, a frail, elderly client
with chronic obstructive pulmonary disease with pneumonia, crackles in the lungs and low O2 saturation can impact adequate
is admitted for pneumonia. The client has a oxygenation, which should be reported to the healthcare provider
long history of smoking and still smokes a
pack of cigarettes a day. Which finding
should the registered nurse report to the
healthcare provider?
a. barrel chest with increased chest
diameter
b. crackles and pulse oximetry level of 88%
c. low hemoglobin and hematocrit levels
d. arterial blood gases indicating respiratory
acidosis
A client who is a Jehovah's witness is B
admitted to the nursing unit. Which concern
should the nurse have for planning care in blood transfusions are forbidden in the Jehovah Witness religion
terms of the client's beliefs?
a. autopsy of the body is prohibited
b. blood transfusions are forbidden
c. alcohol use in any form is not allowed
d. a vegetarian diet must be followed
A client who is in hospice care complains of A
increasing amounts of pain. The healthcare
provider prescribes an analgesic every 4 The most effective management of pain is achieved using an around the clock
hours as needed. Which action should the schedule that provides analgesic medication on a regular basis and in a timely manner
nurse implement?
a. give an around the clock schedule for
administration of analgesics
b. administer analgesic medication as
needed when the pain is severe
c. provide medication to keep the client
sedated and unaware of stimuli
d. Offer a medication-free period so that
the client can do daily activities
department with fever and cough. The nurse
obtains her vitals, listens to her lung and
heart sounds, determines her level of
comfort, and collects blood and sputum
samples for analysis. which standard of
practice is performed?
a. diagnosis
b. evaluation
c. assessment
d. implementation
An adult male client with a history of A
hypertension tells the nurse that he is tired
of taking antihypertensive medications and the prolonged practice of meditation may lead to a reduced need for
is going to try spiritual meditation instead. antihypertensive medications. However, the medications must be continued while the
What should be the nurse's first response? physiologic response to meditation is monitored.
a. "it is important that you continue your
medication while learning to meditate."
b. "spiritual meditation requires a time
commitment of 15 to 20 minutes daily."
c. "obtain your healthcare provider's
permission before starting meditation."
d. "complementary therapy and western
medicine can be effective for you."
,after a recent total hip replacement, an D
older female client, who transferred into a
rehab facility placement, asks the RN if she the best response provides the client with an explanation based on aging and
broke her hip because she is old. How demineralization of the bone in older females especially after menopause
should the RN best respond?
a. hip fractures can occur in any age group
and require strength conditioning
b. with aging, everything tends to break
down more easily the older one gets
c. older people tend to look down instead
of ahead, increasing the risk of falls
d. older women commonly lose bone
calcium which increases the risk of fracture
after a transurethral resection of the A
prostate, an older man returns to the
medical surgical floor with 3-way cath. The the feeling of urgency can be caused by blood clots that can occult the drainage of
RN observes the cath's tubing for drainage the cath, which is common occurrence in the first 72 hours after TURP.
when the client states that he needs to void.
What should the RN implement based on
this finding?
a. irrigate the bladder though the cath port
b. remove cath
c. explain that urgency is expected
d. notify healthcare provider of the
symptom
, After taking a 10-day course of an antibiotic B
that was ineffective, a frail, elderly client
with chronic obstructive pulmonary disease with pneumonia, crackles in the lungs and low O2 saturation can impact adequate
is admitted for pneumonia. The client has a oxygenation, which should be reported to the healthcare provider
long history of smoking and still smokes a
pack of cigarettes a day. Which finding
should the registered nurse report to the
healthcare provider?
a. barrel chest with increased chest
diameter
b. crackles and pulse oximetry level of 88%
c. low hemoglobin and hematocrit levels
d. arterial blood gases indicating respiratory
acidosis
A client who is a Jehovah's witness is B
admitted to the nursing unit. Which concern
should the nurse have for planning care in blood transfusions are forbidden in the Jehovah Witness religion
terms of the client's beliefs?
a. autopsy of the body is prohibited
b. blood transfusions are forbidden
c. alcohol use in any form is not allowed
d. a vegetarian diet must be followed
A client who is in hospice care complains of A
increasing amounts of pain. The healthcare
provider prescribes an analgesic every 4 The most effective management of pain is achieved using an around the clock
hours as needed. Which action should the schedule that provides analgesic medication on a regular basis and in a timely manner
nurse implement?
a. give an around the clock schedule for
administration of analgesics
b. administer analgesic medication as
needed when the pain is severe
c. provide medication to keep the client
sedated and unaware of stimuli
d. Offer a medication-free period so that
the client can do daily activities
