NURS 115 Exam 1 Questions

During the communication process, "decoding" is: a. The selection of words by the sender b. The interpretation of the message by the receiver c. The method by which the message is given d. The way in which feedback is interpreted - b. the interpretation of the message by the receiver The nurse is teaching the client about his upcoming procedure and the client is very stressed. It would be most important for the nurse to: a. use humor first to decrease the client's stress level b. determine if teaching should take place at a different time c. introduce himself as the RN to give credibility to his message d. speak to the client when family members are there so they can teach the client - b. determine if teaching should take place at a different time Use of the statements "Tell me more about..." or "I see" encourage clients to continue talking and expressing themselves. This is called: a. Summarizing b. Open-ended questions c. Focusing d. Encouraging elaboration - d. encouraging elaboration Which religion opposes the "false teaching" of other sects, which often extends to modern science, including medicine? a. Native American b. Unification church c. Buddhism d. Jehovah's Witnesses - d. Jehovah's Witnesses It would be most important for the nurse to instruct the LNA to assist patients of which faith to wash their hands before meals? a. Christian b. Jewish c. Mormon d. Muslim - d. Muslim Joe was asked to make a list of 20 words that describe him. After 15 minutes, Joe listed the following: 25 years old, male, named Joe; the delayed he couldn't think of anything else. He has demonstrated which of the following? a. lack of self-esteem b. deficient self-knowledge c. unrealistic self-expectation d. inability to evaluate himself - b. deficient self-knowledge Which of the nursing interventions below is least likely to assist a severely ill patient with cancer to maintain a positive sense of self? a. making it a point to address the patient by name each time you enter the room b. fatiguing the patient as little as possible by performing all procedures in silence c. continuing to respect the patient's privacy and sensibilities d. offering the patient a simple explanation before moving her in any way - b. fatiguing the patient as little as possible by performing all procedures in silence By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain. - A. Reassess the client to determine the reasons for inadequate pain relief. A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. assessment b. planning c. intervention d. evaluation - a. assessment (the nurse should have used the assessment step by asking the patient to rate the severity of pain on a 0 to 10 scale) A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) a. respiratory rate that is 22/min with even, unlabored respirations b. the client's partner states, "they said they hurt after walking about 10 minutes" c. the client's pain rating is 3 on a scale of 0 to 10 d. the client's skin is pink, warm, and dry e. the assistive personnel reports that the client walked with a limp - a. respiratory rate that is 22/min with even, unlabored respirations (vital signs) d. the client's skin is pink, warm, and dry (skin appearance) e. the assistive personnel reports that the client walked with a limp (family and staff) A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) a. writing a prescription for morphine sulfate as needed for pain b. inserting a nasogastric (NG) tube to relieve gastric distention c. showing a client how to use progressive muscle relaxation d. performing a daily bath after the evening meal e. repositioning a client every 2 hr to reduce pressure injury risk - c. showing a client how to use progressive muscle relaxation d. performing a daily bath after the evening meal e. repositioning a client every 2 hr to reduce pressure injury risk A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? a. "I will determine the most important client problems that we should address" b. "I will review the past medical history on the client's record to get more information" c. "I will carry out the new prescriptions from the provider" d. "I will ask the client if their nausea has resolved" - a. "I will determine the most important client problems that we should address" A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? a. decreased subcutaneous fat b. muscle atrophy c. pressure injury d. fecal impaction - c. pressure injury A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) a. instruct the client not to perform the Valsalva maneuver b. apply elastic stockings c. review laboratory values for total protein level d. place pillows under the client's knees and lower extremities e. assist the client to change positions often - b. apply elastic stockings e. assist the client to change positions often (not d. pillows can impair circulation) A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? a. encourage the client to perform antiembolic exercises every 2 hr b. instruct the client to cough and deep breathe ever 4 hr c. restrict the client's fluid intake d. reposition the client every 4 hr - a. encourage the client to perform antiembolic exercises every 2 hr A nurse is evaluating a client's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? a. "The device will keep me from getting sores on my skin" b. "This device will keep the blood pumping through my leg" c. "With this device on, my leg muscles won't get weak" d. "This device is going to keep my joints in good shape" - b. "This device will keep the blood pumping through my leg" A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) a. hold the cane on the right side b. keep two points of support on the floor c. place the cane 38 cm (15 in) in front of the feet before advancing d. after advancing the cane, move the weaker leg forward e. advance the stronger leg so that it aligns evenly with the cane - a. hold the cane on the right side b. keep two points of support on the floor d. after advancing the cane, move the weaker leg forward A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should ht nurse use for safe care of this client? a. supine b. semi-fowler's c. semi-prone d. trendelenburg - b. semi-fowler's A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? a. obtain a walker for the client to use to transfer back to bed b. call for additional staff to assist with the transfer c. use a transfer belt and assist the client back into bed d. determine the client's ability to help with the transfer - d. determine the client's ability to help with the transfer A nurse is instructing a client who has COPD about using the orthopedic position to relieve shortness of breath. Which of the following statements should the nurse make? a. "Lie on your back with your head and shoulders supported by a pillow" b. "Have your head turned to the side while you lie on your stomach" c. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table" d. "Lie on your side with your top arm resting on the bed and your weight on your hip" - c. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table" A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) a. request assistance when repositioning a client b. avoid twisting your spine or bending at the waist c. keep your knees slightly lower than your hips when sitting for long periods of time d. use smooth movements when lifting and moving clients e. take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles - a. request assistance when repositioning a client b. avoid twisting your spine or bending at the waist d. use smooth movements when lifting and moving clients A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) a. "My line of gravity should fall outside my base of support" b. "The lower my center of gravity, the more stability I will have" c. "To broaden my base of support, I should spread my feet apart" d. "When I lift an object, I should hold it as close to my body as possible" e. "When pulling an object, I should move my front foot forward" - b. "The lower my center of gravity, the more stability I will have" c. "To broaden my base of support, I should spread my feet apart" d. "When I lift an object, I should hold it as close to my body as possible" A nurse is caring for a client who states, "I have to check with my partner and see f they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? a. pacing b. reflecting c. paraphrasing d. restating - b. reflecting Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.) a. use an open posture b. write down what the client says to avoid forgetting details c. establish and maintain eye contact d. nod in agreement with the client throughout the conversation e. sit facing the client - a. use an open posture c. establish and maintain eye contact e. sit facing the client A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) a. "you will do great! you just have to get used to it." b. "why are you worried about going home?" c. "your daily routines will be different when you get home" d. "tell me about the support system you'll have after you leave the hospital." e. "it sounds like you are not sure how having a colostomy will affect swimming" - c. "your daily routines will be different when you get home" d. "tell me about the support system you'll have after you leave the hospital." e. "it sounds like you are not sure how having a colostomy will affect swimming"