A nurse is preparing a change-of-shift report for a patient who had chest pain. Which information is
critical for the nurse to include? - ANSWER Sharp pain of 8 on a scale of 1 to 10
A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the
nurse using? - ANSWER Personal
While teaching the client about management of his heart disease, a nurse might use a strategy that is
implemented to promote learning in the affective domain such as: - ANSWER Encouraging the client to
personally discuss his feelings about his health status
An incident report is to be completed because the client climbed over the side rails and fell to the floor.
The correct reporting of an incident involves which of the following? - ANSWER The witnessing nurse
completes the report
The staff is having a hard time getting an older adult patient to communicate. Which technique should
the nurse suggest the staff use? - ANSWER Allow the patient to reminisce
When meeting for the first time, the home health nurse smiles warmly and shakes the client's hand. The
nurse-client relationship is in the: - ANSWER Orientation phase
When a client newly diagnosed with type 2 diabetes mellitus selects a lunch menu that correlates with
the number of carbohydrates he is allowed for that meal, this is an example of: - ANSWER Cognitive
learning
A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is
most appropriate for this patient? - ANSWER Impaired verbal communication
A new nurse asks the preceptor why a change-of-shift report is important since care is documented in
the chart. What is the preceptor's best response? - ANSWER provides an opportunity to share essential
information to ensure patient safety and continuity of care
, Nursing documentation should fulfill which of the following criteria? - ANSWER must be accurate,
comprehensive, flexible, maintain continuity of care, track client outcomes, and reflect current standards
There are many factors are assessed before teaching the client to learn insulin injection sites, but the
most important factor for the nurse to assess first is the: - ANSWER The willingness of the client to want
to learn the injection sites
Which of the following is a good dietary choice for calcium? - ANSWER Spinach
What factors predispose patients to pressure ulcer development? - ANSWER Alteration in level of
consciousness
What electrolyte imbalance is the nurse most concerned about when giving a diuretic? - ANSWER
Potassium imbalance
The palliative team's PRIMARY obligation to a patient in severe pain includes which of the following? -
ANSWER Enhancing the patient's quality of life
What is delirium? - ANSWER acute mental disorder with symptoms of confusion, disorientation, and
restlessness
A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the
front desk of the nursing station so patients can be located easily. What action is most appropriate for
the nurse to take? - ANSWER Use the book as needed while keeping it away from individuals not
involved in patient care.
The nurse has become aware of missing narcotics in the patient care area. Which ethical principle
obligates the nurse to report the missing medications? - ANSWER Responsibility
Greater trochanter, thumb pointing to groin, and anterior superior iliac spine are parts of the landmarks
for which type site? - ANSWER ventrogluteal