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NURSING 1140Exam #2 Study Guide

NURSING 1140Exam #2 Study Guide 1 Chapter 10 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 10 Question 1 The nurse is providing care to a group of clients. For which situation would the nurse’s use of critical thinking be a priority? 1. Administering IV push meds to critically ill clients 2. Educating a home health client about treatment options 3. Teaching new parents car seat safety 4. Assisting an orthopedic client with the proper use of crutches Question 2 A client recovering from a stroke does not want to perform prescribed shoulder exercises. What should the nurse say to the client that demonstrates critical thinking with creativity? 1. “You’ll only get worse if you don’t do these exercises.” 2. “As soon as you get these into your routine, you’ll feel better.” 3. “Your physician wouldn’t have ordered these if they weren’t important.” 4. “Here’s a marker. See how many circles you can make on this board in 10 minutes.” Question 3 A student nurse resists when encouraged to be creative when providing client care. What should the nurse educator say to encourage this student to be creative? 1. “Creativity allows unique solutions to unique problems.” 2. “Not all your answers are going to be from your textbook.” 3. “Creativity makes nursing more fun.”2 4. “You’ll get bored if you don’t learn to be creative.” Question 4 The nurse educator assigns students an activity to implement Socratic questioning in their daily lives. Which question provided by a student demonstrates this reasoning technique? 1. “What makes you think cramming for a test is an ineffective way to study?” 2. “What other ways of studying could you implement?” 3. “If you didn’t study for your test, what is the probability you will fail?” 4. “If you study all the unit outcomes, what effect will that have?” Correct Answer: 1 Question 5 A client is experiencing a productive cough, audible coarse crackles, elevated temperature of 102.3°F, chills, and body aches. What did the nurse use to determine that this patient is experiencing respiratory compromise? 1. Deductive reasoning 2. Inductive reasoning 3. Socratic questioning 4. Critical analysis Correct Answer: 1 Question 6 A client with a PhD in epidemiology has been to numerous physicians and has had numerous laboratory tests, all of which were abnormal, and exploratory surgery, but no one is able to explain the etiology of his problem. The client also states that he has a rare form of a neurological disorder. Which statement should the nurse make that demonstrates critical thinking? 1. “Why don’t you just tell your physician what you think you have?” 2. “Did you bring your prior tests and results with you, so we don’t repeat anything?”3 3. “If you know what you have, what do you want from us?” 4. “Describe what tests you’ve had and explain the symptoms of this disorder.” Question 7 A nurse educator has always believed that lectures with focused outlines are the best way to present theory content in class. A colleague, who teaches the same group of students, but a different subject, utilizes group work and in-class activities to teach difficult content and finds that students perform as well, or better, on their tests. The first educator in this situation is starting to rethink her position. What behavior is the first educator demonstrating? 1. Integrity 2. Perseverance 3. Fair-mindedness 4. Humility Correct Answer: 1 Question 8 The nurse who just moved from an urban area to a sparsely populated rural area understands that certain customs and practices the nurse follows may be quite foreign to the people in the new area. Which attitude of critical thinking is the nurse demonstrating? 1. Fair-mindedness 2. Insight into egocentricity 3. Intellectual humility 4. Intellectual courage to challenge the status quo and rituals Question 9 The nurse implements a quicker way to set up and initiate an intravenous infusion while still following safe practice. Which attitude of critical thinking is this nurse practicing? 1. Independence 2. Intellectual courage to challenge the status quo or rituals4 3. Integrity 4. Confidence Question 10 The nurse questions the practice of administering rectal suppositories to residents in a long-term care facility at bedtime, rather than earlier in the day. When told that this is the best time for staff and that’s the routine that has been practiced for a long time, the nurse continues to research whether there would be a better time, especially in the best interest of the residents. Which critical thinking attitude is this nurse demonstrating? 1. Confidence 2. Perseverance 3. Curiosity 4. Integrity Correct Answer: 3 Question 11 A seasoned nurse uses past experiences and knowledge gained from previous care situations to care for a client with complex health issues. Which attribute of critical thinking is this nurse practicing? 1. Reflection 2. Context 3. Dialogue 4. Time Question 12 While listening to a client describe current symptoms, the nurse considers the client’s entire situation. Which attribute of critical thinking is the nurse practicing?5 1. Reflection 2. Context 3. Dialogue 4. Time Question 13 A client complaining of shortness of breath has no pallor, cyanosis, or use of accessory muscles with respirations. The client’s respiratory rate is 16 breaths per minute. The nurse is concerned that the client’s report and the physical findings conflict. Which standard of critical thinking is the nurse using? 1. Clarity 2. Accuracy 3. Logical reasoning 4. Significance Question 14 The nurse enters the room of a critically ill child after sensing that “something” isn’t right. Once the nurse determines the child is stable, the nurse continues to perform a check of all the lines and equipment in the room and finds that the last IV solution hung by the previous nurse was not the correct solution. Which problem–solving method did this nurse use? 1. Trial and error 2. Intuition 3. Judgment 4. Scientific method Correct Answer: 2 Question 156 The nurse systematically tries a variety of products to help with healing of a client’s wound. Which problem–solving method is the nurse using? 1. Intuition 2. Scientific method 3. Research process 4. Trial and error Question 16 A client with unstable cardiac dysrhythmias has orders for medications, one of which is by oral route, the other by IV delivery. The nurse realizes that the IV route would be fastest, but is also concerned about the side effects that this drug may produce and the fact that the client has never taken the drug, so any adverse effect is unknown. Which part of the decision-making process is the nurse using? 1. Identify the purpose 2. Seek alternatives 3. Project 4. Implement Question 17 Prior to providing client care, the nurse reviews previous shift charting and the responses to nursing interventions. Which decision-making action is the nurse using? 1. Set the criteria 2. Examine alternatives 3. Implement 4. Evaluate the outcome Question 187 Parents ask why invasive diagnostic tests were prescribed for their ill child. The nurse has just gotten out of report and has not had a chance to review additional information. What should the nurse respond to the parents? 1. “I’m not sure I can answer your question just now.” 2. “It’s a good idea to listen to what your physician wants.” 3. “Your child’s doctor is the best there is. I don’t see why you wouldn’t follow his advice.” 4. “Maybe you should get another opinion if you’re not comfortable with your doctor.” Question 19 A client complaining of “extreme” low back pain is pale and diaphoretic and walks bent at the waist. Before taking vital signs, the nurse suspects that the blood pressure and heart rate will be elevated. What thought process did the nurse use to come to this conclusion? 1. Fact 2. Inference 3. Judgment 4. Opinion Question 20 The nurse completes collecting data from a client and determines a list of problems. Which step in the nursing process should the nurse perform next? 1. Assess 2. Diagnose 3. Plan 4. Evaluate Question 21 While caring for a client of a different culture, the nurse becomes disturbed when the client’s spouse makes all the decisions about care and treatments. What behavior is this nurse demonstrating?8 1. Inference 2. Judgment 3. Opinion 4. Evaluation Question 22 The staff nurse asks why unlicensed assistive personnel are responsible for stocking the unit refrigerator with refreshments when dietary personnel place the items on the shelf in the kitchen. What characteristic of critical thinking is this nurse demonstrating? 1. Curiosity 2. Clinical reasoning 3. Setting priorities 4. Developing rationales Question 23 A clinical instructor senses that a student has been struggling with clinical skills learned in lab. To combat this, the educator pairs the student with a staff nurse who has clients with a variety of treatments and cares. Which type of problem solving is the instructor using? 1. Trial and error 2. Intuition 3. Research process 4. Experience Question 24 The nurse desires to improve critical thinking skills when providing client care. On which attributes should the nurse focus when developing these skills?9 Standard Text: Select all that apply. 1. Independence 2. Egocentricity 3. Intellectual humility 4. Fair-mindedness 5. Confidence 6. Perseverance Question 25 During a clinical conference, a staff nurse states that critical thinking is essential when providing client care. What additional statements should this nurse make to support the use of critical thinking? Standard Text: Select all that apply. 1. “Patient acuity is so much greater than it was even 10 years ago.” 2. “Care delivery systems are only as good as the nurses delivering care.” 3. “Nurses have always relied on commonsense thinking to provide quality, appropriate nursing care.” 4. “With health care being so expensive, nursing has to take on responsibility to keep the costs controlled.” 5. “My practice involves caring for clients who require care that didn’t even exist when I went to school.” Question 26 The nurse manager determines that a new staff nurse is demonstrating characteristics of a critical thinker. What did the manager observe the nurse perform? Standard Text: Select all that apply. 1. Listening with empathy to a client who recently has been diagnosed.10 2. Waiting for the medical team to determine the focus of the client’s supportive care. 3. Questioning a medication order that does not appear to meet the client’s needs for pain management. 4. Exhibiting a willingness to try alternate methods of addressing a client’s care needs. 5. Practicing nursing in a culturally competent fashion. Question 27 Type: MCMA The staff nurse is helping a new graduate understand the relationship between care concepts and planned interventions. What value would it be for the staff nurse to encourage the new graduate to use a concept map? Standard Text: Select all that apply. 1. Used to highlight key areas 2. Provides a visual representation 3. Can be quicker than taking notes 4. Takes years to study how to create 5. Aids in developing critical thinking Chapter 13 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 13 Question 111 Type: MCSA A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this client’s care? 1. The admitting nurse 2. All nurses who work with the client 3. Everybody involved in this client’s care 4. The client and the client’s support system Question 2 A client is admitted for complications following a routine diagnostic procedure of the colon. Which type of care plan will most likely be implemented for this client? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Correct Answer: 4 Question 3 A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this client’s care? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan Correct Answer: 312 Question 4 The nurse being oriented to a new position is reviewing the hospital’s standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff? 1. Making sure all clients have the same types of care 2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurse’s time 4. Eliminating care disparities among clients 5. Ensuring medication errors do not occur Question 5 The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant. Which type of document did the nurse use to find these actions? 1. Standardized care plan 2. Protocol 3. Standards of care 4. Policy and procedure manual Question 6 A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation? 1. A STAT order 2. A one-time order 3. A prn order 4. A standing order13 Correct Answer: 4 Question 7 According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client? 1. Make sure that he or she is able to get to the client’s home. 2. Assist the client in finding an alternative plan for the achieving the therapy’s outcomes. 3. Tell the client that this therapy will be impossible to receive. 4. Make arrangements to have the client moved to a long-term care facility. Question 8 A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? 1. Client will ambulate without a walker by 6 weeks. 2. Client will ambulate freely in house. 3. Client will not fall. 4. Client will have freer movement in daily activities. Question 9 The nurse identifies for a client the nursing diagnosis “Fluid volume deficit, related to active fluid loss, secondary to diarrhea.” What would be and appropriate goal statement for this diagnosis? 1. Client will drink more fluids by tomorrow. 2. Client will have good skin turgor. 3. Client will have moist mucous membranes. 4. Client will have intake of at least 1000 mL within 24 hours.14 Question 10 The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy? 1. Nursing diagnosis statement 2. Planning portion of the care plan 3. Goal statement of the traditional care plan 4. Implementation phase of the care plan Question 11 The nurse is caring for a client with Parkinson’s disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client? 1. Provide assistance as needed with dressing and grooming. 2. Provide assistive devices and educate client to use grab bar and large handled utensils. 3. Make sure lighting and space are adequate for client. 4. Administer medications to improve muscle tone. Question 12 The nurse is reviewing interventions written for a client’s plan of care. Which intervention should the nurse recognize as being dependent? 1. Repositioning the client every 2 hours 2. Assisting the client with transfers to the bathroom 3. Providing ongoing physical assessment, especially of the incisional sites 4. Administering medications for pain Question 1315 One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? 1. 60 to 90 degrees during feeding times 2. Position in chair 3. Upright in a chair 4. Impaired swallowing Question 14 A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention? 1. Turn and reposition client every 2 hours. 2. Cushion bony prominences with soft foam while in bed. 3. Provide ongoing assessment for skin breakdown every shift. 4. Apply lotion to dry skin twice daily. Question 15 The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention? 1. Assist client with ambulation. 2. Ambulate with client, using a gait belt, twice daily for 15 minutes. 3. Make sure client understands the rationale for using the gait belt. 4. Client will ambulate in hallway twice daily.16 Question 16 A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve? 1. Help the nurse with documentation of the care plan 2. Require that the nurse use sound judgment and knowledge of the client 3. Match nursing diagnoses to exact interventions 4. Help the nurse choose activities that are individualized to the client Question 17 The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale? 1. Have suction equipment available at all times. 2. Clear secretions from oral/nasal passageways as needed. 3. Keep client in low-Fowler’s position to prevent reflux. 4. Provide frequent assessment for presence of obstructive material in mouth and throat. Question 18 The nurse manager is implementing computerized care plans for the care area. Which guidelines should the manager emphasize when the staff is writing care plans? Standard Text: Select all that apply. 1. Plans must be dated and signed. 2. Categories must have headings. 3. Plans must be specific. 4. Plans must include preventive care and health maintenance. 5. Plans must include interventions for ongoing assessment​.17 6. Plans are standardized and generalized for all clients. Question 19 The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multi-system health care facility. Why are these documents important to the nursing staff when providing client care? Standard Text: Select all that apply. 1. To make sure all clients have the same type of care 2. To ensure that minimally accepted standards of care are met 3. To promote efficient use of the nurse’s time 4. To eliminate care disparities among clients 5. To minimize health care costs Question 20 The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client? Standard Text: Select all that apply. 1. Congruent with the client’s values, beliefs, and culture 2. Are within established standards of care 3. Based on scientific and medical knowledge 4. Achievable with the resources available 5. Must be safe and appropriate for the client’s age Question 2118 The nurse is reviewing a client’s plan of care. Which statements indicate that this care plan has been completed accurately and appropriately? Standard Text: Select all that apply. 1. Ineffective coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms. 5. The client has apologized to his family for drug abuse behaviors. Question 22 The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective? Standard Text: Select all that apply. 1. “I can look up interventions according to the nursing diagnosis that I’ve selected.” 2. “The interventions connected to a diagnosis are appropriate for any client with that diagnosis.” 3. “If there is a NANDA diagnosis, I should be able to find some appropriate interventions.” 4. “Care plans are best written when the interventions are broad and flexible.” 5. “I find NIC interventions a really good place to start when I’m working on client interventions.” Question 23 The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this client’s discharge was started by the nurse? Standard Text: Select all that apply. 1. The client is scheduled for cardiac catheterization and echocardiogram. 2. Recent laboratory data indicates the development of heart failure.19 3. The client does not have a scale to perform daily weights at home. 4. The client’s spouse has care needs that the client will not be able to complete going forward. 5. The client is pleasant and eager to learn how to control newly diagnosed health problem. Chapter 14 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 14 Question 1 The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation? 1. Technical 2. Interpersonal 3. Creativity 4. Cognitive Question 2 A home care client must correctly self-administer insulin injections before being discharged from the agency. On what skill is this client being evaluated? 1. Technical 2. Cognitive 3. Interpersonal 4. Academic Question 3 The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients?20 1. Cognitive 2. Interpersonal 3. Technical 4. Therapeutic Question 4 The nurse is preparing to provide care planned for a client. What actions should the nurse complete during this phase of client care? 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing interventions Question 5 Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform? 1. Implementing nursing intervention 2. Determining the nurse’s need for assistance 3. Supervising delegated care 4. Reassessing the client Question 6 The nurse is caring for a new mother and infant. Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant? 1. Telling the parents everything the nurse is doing and why 2. Letting the parents watch a video after the bath21 3. Letting the parents bathe the baby with direction and guidance from the nurse 4. Giving lots of advice and suggestions about different methods Question 7 During teaching, the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries when self-administering insulin. Which guideline of implementing interventions is the nurse using? 1. Adapt activities to the individual client. 2. Encourage clients to participate actively in implementing nursing interventions. 3. Base nursing interventions on scientific knowledge, research, and standards of care. 4. Implement safe care. Rationale 4: Showing the client how to avoid injury with injections is part of implementing safe care. Question 8 On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take? 1. Ask the nurse mentor to assist with the teaching after reviewing the procedure. 2. Read the policy and procedure manual before the teaching session. 3. Do the best the nurse can by remembering what was taught in nursing school. 4. Ask for a different assignment until the nurse feels comfortable with this one. Question 9 A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do? 1. Follow the physician’s orders as written and give the medication. 2. Call the pharmacy and do further investigating before administering the medication. 3. Ask the client about this medication.22 4. Call the physician and ask what the medication is and what it is for. Question 10 The nurse is providing care to an assigned client. Which action indicates that the nurse supports the client’s respect for dignity? 1. Allowing the client to complete hygienic care when possible 2. Providing all care to the client whenever possible 3. Telling the other staff that the client is demanding, so they are able to meet the client’s needs 4. Presenting information to the client’s family about the client’s condition Question 11 The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next? 1. Move on to the next assignment to increase the nurse’s efficiency. 2. Report this to the charge nurse. 3. Document all care in the progress notes. 4. Get supplies organized for the next client’s medications and treatments. Question 12 The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? 1. Assessment is done at the beginning of the process. 2. Evaluation is completed at the end of the process. 3. They are the same and there is no need to differentiate. 4. The difference is in how the data are used.23 Question 13 The nurse notes that a client has the outcome goal “Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic.” Which client statement should the nurse use to evaluate this goal? 1. “I’m getting really sleepy from that medication. I think I’ll take a nap.” 2. “My pain is a 4.” 3. “I still have some pain.” 4. “Will the pain ever go away?” Question 14 A client has the goal statement “Client will be able to state two positive aspects of rehab therapy by the end of the week.” What statement demonstrates that the nurse appropriately evaluated this goal? 1. Goal not met, client able to state one positive aspect by the end of the week. 2. Goal met, client able to state one positive aspect by the end of the week. 3. Goal met, client able to state two positive aspects of therapy by week’s end. 4. Goal incomplete, client not able to positively state anything about rehab. Question 15 A client has the goal statement “Client will have clear lung sounds bilaterally within 3 days.” One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the client’s lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? 1. Ask how many times per day the client practiced the coughing and deep breathing exercises. 2. Tell the client that the lungs are clear. 3. Document the assessment findings to show the effectiveness of the intervention.24 4. Write this evaluation statement: Goal met, lung sounds clear by third day. Question 16 A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the client’s symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the nurse do? 1. Keep the problem on the care plan, in case the symptoms return. 2. Document that the problem has been resolved and discontinue the care for the problem. 3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. 4. Document that the potential problem is being prevented because the symptoms have stopped. Question 17 A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan? 1. The goal statement is written inaccurately. 2. The interventions are dependent of nursing. 3. The goal is unrealistic. 4. The interventions are not clear enough. Question 18 A teenage client has been having problems with peer support, school performance, and parental expectations, all of which contributed to an eating disorder. After gathering this assessment data, the nurse formulates the diagnosis Activity Intolerance related to weakness. What should the nurse realize after evaluating this diagnosis?25 1. The data collected would support the diagnosis. 2. The diagnosis is directly related to the data presented. 3. The nursing diagnosis is not relevant to the data. 4. The data are not sufficient enough to support this diagnosis. Question 19 A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month; however, the client has fallen several times. In this situation, what should the nurse do? 1. Review the data and make sure that the diagnosis is relevant. 2. Investigate whether the best nursing interventions were selected. 3. Modify the whole nursing plan. 4. Discard the nursing plan and start over from the assessment phase. Question 20 The nurse manager has been appointed to implement a quality assurance program at the hospital. Which components should the manager prepare to evaluate for this program? 1. Methods 2. Structure 3. Finances 4. Process 5. Outcome Question 21 A care area has been short staffed for the past month with a heavy client load and high acuity. The nurses have been working extra as well as double shifts and often do not have time to make sure26 that properly working equipment is cleaned, returned, and stored in the appropriate areas. At what level should this care area be evaluated? 1. Management 2. Structure 3. Process 4. Outcome Question 22 A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. When evaluating this care area, on which care component should the quality assurance officer focus? 1. Competency 2. Structure 3. Process 4. Outcome Question 23 A nursing unit’s records of client care have been reviewed for accuracy in documentation. Which type of review is being completed on these records? 1. Nursing audit 2. Peer review 3. Individual audit 4. Concurrent audit Question 24 The nurse reviews clients’ records and the care they received while in the hospital for an insurance company. Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse completing? 1. Concurrent27 2. Peer review 3. Nursing audit 4. Retrospective Question 25 The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out? 1. Delegating to the appropriate staff 2. Delegating the appropriate task 3. Selecting the appropriate client 4. Appropriately supervising care Question 26 The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process? Standard Text: Select all that apply. 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing intervention Question 27 After implementing interventions and reassessing the client’s response, the nurse completes the process by evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing process?28 Standard Text: Select all that apply. 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinion Question 28 The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process? Standard Text: Select all that apply. 1. Effectively assessing the client’s needs 2. Selecting the appropriate nursing diagnosis related to the client’s needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes 5. Basing evaluation on assessment data collected during the admission phase Question 29 The nurse notes that assessment data indicate a change in a client’s condition. What should the nurse ask before changing this client’s plan of care? Standard Text: Select all that apply. 1. How difficult will it be to change the care plan? 2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan?29 5. Will the primary medical provider agree with the need to alter the care plan? Question 30 The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? Standard Text: Select all that apply. 1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan 5. Physician notified of changes in the care plan Question 31 A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence? Standard Text: Select all that apply. 1. A root cause analysis 2. Paperwork about a sentinel event 3. Analysis of the nurse assigned to the client 4. Number of times the client was observed on the night shift 5. Number of hours since the client last received pain medication Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 1530 Question 1 A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with him, as it’s his record. How should the nurse respond to this client’s request? 1. “You’ll have to ask your doctor for permission to do that.” 2. “Actually, the original record is the property of the hospital, but you are welcome to copies of your records.” 3. “We’ll make sure that all of your records are sent ahead to the rehab hospital, so you don’t really have to worry about those details.” 4. “There’s a new law that protects your records, so you’re not going to be able to have access to them.” Question 2 After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it’s permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond? 1. “Confidentiality and privacy laws don’t apply to students.” 2. “Most students review so many records and charts that they could not possibly remember details from any one of them.” 3. “Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence.” 4. “As long as the clinical instructor is in the area, accessing client records is part of the education process.” Question 3 The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records? 1. A firewall to protect the server from unauthorized access 2. One unit password to protect the unit’s information 3. Expectation to log off a terminal after using it31 4. Expectation to turn the monitor away from view when unattended 5. Requirement to shred all computer-generated worksheets Question 4 A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which problem with documentation might have caused the lack of reimbursement? 1. The client’s record contained an incorrect DRG. 2. The client was charged for an ECG. 3. A code cart was opened and the client was charged for medications opened but not used. 4. The physician made a diagnostic mistake. Question 5 When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the client’s chart. Which type of documentation system is the nurse using? 1. Source-oriented record 2. Problem-oriented record 3. Case management 4. Focus charting Question 6 The nurse makes chronological entries in a client’s chart that include documentation about the routine care provided, assessment findings, and client problems during a 12–hour shift. Which type of charting is this nurse completing? 1. Problem-oriented recording 2. Source-oriented recording32 3. Narrative charting 4. Plan of care Question 7 The nurse is reviewing a client’s chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Question 8 A client has specific cultural needs that affect the plan of care. In which part of the client’s problem-oriented medical record should the nurse document this information? 1. Database 2. Problem list 3. Plan of care 4. Progress notes Question 9 The client states: “I really don’t want anyone to visit me who has not been cleared by me first.” If utilizing SOAP format, in which category should the nurse document this statement? 1. Subjective data 2. Objective data 3. Assessment 4. Planning33 Question 10 The nurse administered analgesic medications to an assigned client via central line. In which section of PIE charting should the nurse document this information? 1. Plan 2. Intervention 3. Evaluation 4. Progress notes Question 11 The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using? 1. Computerized documentation 2. Focus charting 3. SOAP charting 4. Charting by exception Correct Answer: 4 Question 12 The nurse working in a hospital that utilizes a charting by exception (CBE) documentation system notes that a client did not require care in all of the areas identified on a flow sheet. What action should the nurse take? 1. Leave the areas blank. 2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the chart. 3. Write N/A on the flow sheet in the areas that are not applicable to that client.34 4. Make sure this information gets passed along in the shift report. Correct Answer: 3 Question 13 A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following? 1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation Question 14 A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. Which type of form is this hospital utilizing? 1. Standardized care plans 2. Traditional care plans 3. Critical pathways 4. Kardex Question 15 Before providing care, the nurse reviews the client’s pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information? 1. The client’s medical record35 2. The MAR (medication administration record) 3. The written care plan 4. The Kardex Question 16 The nurse is teaching medication administration to a client being discharged. Which instruction should the nurse rewrite for this client? 1. Lasix, 20 mg, po bid 2. Lasix, 20 mg tablet, twice daily 3. Lasix, 20 mg by mouth, two times a day a day 4. Lasix, 20 mg by mouth 8 AM and 2 PM Question 17 A client in long-term care is scheduled for a review of the assessment and care screening process. Where should the nurse document this information? 1. MDS 2. OBRA 3. CBE 4. Kardex Question 18 When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding? 1. Client fell out of bed, but did push the call button for assistance. 2. Client became tangled in the bed linens, then called for assistance after falling out of bed.36 3. Recorder responded to client’s call light, upon entering the room, found client on floor. 4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens. Question 19 After completing the client care and documenting it in the progress notes, the nurse realizes that documentation was placed on the wrong medical record. What should the nurse do? 1. Use white-out over the mistake. 2. Take a wide permanent marker and blacken out all the documentation. 3. Put an “X” through the entire page, identify it as an “error,” initial, and move on to the correct chart. 4. Draw a single line through the documentation, write “mistaken entry” next to the original entry, and initial it. Question 20 The nurse manager is conducting a survey of personnel to see what the general feeling is before implementing computerized charting in an acute care hospital. What should the nurse select as positive aspects of implementing this type of system? Standard Text: Select all that apply. 1. The system is relatively inexpensive to maintain. 2. Bedside terminals eliminate worksheets and note taking. 3. The system links to various sources of client information. 4. The system better protects client privacy. 5. Information is legible. 6. Results, requests, and client information can be sent and received quickly.37 Chapter 30 Kozier & Erb’s ​Fundamentals of Nursing​, 10/E Chapter 30 Question 1 The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment? 1. ​Auscultate, percuss, palpate, inspect 2. ​Inspect, auscultate, palpate, percuss 3. ​Inspect, auscultate, percuss, palpate 4. ​Palpate, percuss, auscultate, inspect Question 2 The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being 1. ​cyanosis. 2. ​jaundice. 3. ​pallor. 4. ​erythema. Question 3 While performing an assessment of the integument system, the nurse notes the client’s eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding? 1. ​Erythema 2. ​Cyanosis 3. ​Exophthalmos38 4. ​Normocephalic Question 4 The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel? 1. ​Vital signs 2. ​Filling of water pitchers 3. ​Skull and face assessment 4. ​Ambulation of surgical clients Question 5 The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately? 1. ​Chest symmetrical 2. ​Breath sounds equal bilaterally 3. ​Asymmetrical chest expansion 4. ​Bilateral symmetric vocal fremitus Question 6 While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins? 1. ​90-degree angle 2. ​30- to 45-degree angle 3. ​15-degree angle 4. ​60-degree angle39 Question 7 The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately? 1. ​Pulses equal bilaterally 2. ​Full pulsations 3. ​Thready pulses 4. ​Pulses present bilaterally Question 8 During the assessment of a client’s breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next? 1. ​Notify the charge nurse. 2. ​Notify the physician. 3. ​Document the findings in the nurse’s notes as normal. 4. ​Document the findings in the nurse’s notes as abnormal. Question 9 The nurse is preparing a client for an abdominal examination. What should the nurse done before beginning the examination? 1. ​Ask the client to urinate. 2. ​Ask the client to drink 8 ounces of water. 3. ​Assess vital signs. 4. ​Assess heart rate.40 Question 10 The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action? 1. ​Grasp the nurse’s index and middle fingers while the nurse tries to pull the fingers out. 2. ​Hold an arm up and resist while the nurse tries to push it down. 3. ​Flex each arm and then try to extend it against the nurse’s attempt to keep the arm in flexion. 4. ​Shrug the shoulders against the resistance of the nurse’s hands. Question 11 The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment? 1. ​Cognitive and affective functions 2. ​Cognitive and effective functions 3. ​Affective and memory functions 4. ​Affective and knowledge functions Question 12 The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 1. ​Auditory aphasia 2. ​Acoustic aphasia 3. ​Sensory aphasia 4. ​Expressive aphasia Question 1341 The nurse is preparing to assess a client’s reflexes. What equipment should the nurse gather before entering the room? 1. ​Sterile gloves 2. ​Clean gloves 3. ​Percussion hammer 4. ​Penlight Question 14 The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the health care provider to perform? 1. ​Pap test 2. ​Breast exam 3. ​Rectal exam 4. ​Abdominal exam Question 15 The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel? 1. ​Neurological assessment 2. ​Musculoskeletal assessment 3. ​Vital signs assessment 4. ​Female genital assessment Question 16 The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication?42 1. ​Respiratory rate 2. ​Apical pulse 3. ​Popliteal pulse 4. ​Capillary blanch test Question 17 The nurse is preparing to complete a physical examination on a client. What should the nurse realize as being the purpose for this examination? Standard Text: ​Select all that apply. 1. ​Obtain baseline data. 2. ​Obtain data to help determine nursing diagnoses. 3. ​Identify areas for disease prevention. 4. ​Identify the client’s employment status. 5. ​Obtain data about the client’s leisure activities. Question 18 A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine Standard Text: ​Select all that apply. 1. ​the progress of the client’s health problem. 2. ​the physiological impact of the prescribed medication. 3. ​baseline data. 4. ​data to support nursing diagnoses. 5. ​areas for health promotion.43 Question 19 The nurse is utilizing the technique of inspection during a physical examination with a client. When using this technique, the nurse will take which actions? Standard Text: ​Select all that apply. 1. ​Visually observe a body area. 2. ​Obtain information through the sense of smell. 3. ​Obtain information through the sense of hearing. 4. ​Examine the body through the use of touch. 5. ​Strike the body to elicit a sound from a body part. Question 20 The nurse is planning to perform indirect percussion on an area of a client’s body during a physical examination. Which actions should the nurse take to use this assessment technique? Standard Text: ​Select all that apply. 1. ​Place the middle finger of the nondominant hand on the client’s skin. 2. ​Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand. 3. ​Perform a striking motion by moving the wrist. 4. ​Perform short, rapid, firm blows. 5. ​Use a stethoscope to transmit sounds to the ears. Question 21 The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits? Standard Text: ​Select all that apply. 1. ​Nose straight44 2. ​Nares symmetrical 3. ​No tenderness over the bridge 4. ​Air movement restricted in one nare 5. ​Clear drainage from one nare Question 22 The nurse is planning a physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment? 1. ​Head, upper extremities, abdomen, lower extremities 2. ​Neck, head, vital signs, chest and back 3. ​Lower extremities, abdomen, upper extremities, chest and back 4. ​Head, neck, lower extremities, abdomen Question 23 The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client? 1. ​Easy to palpate upper extremity arteries 2. ​Easy to palpate lower extremity arteries 3. ​Reduction in the number of varicosities 4. ​Increase in diastolic blood pressure Question 24 The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? Standard Text: ​Select all that apply.45 1. ​Penlight 2. ​Snellen’s chart 3. ​Sterile gloves 4. ​Gauze square 5. ​Millimeter ruler Question 25 The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? Standard Text: ​Select all that apply. 1. ​Aortic region 2. ​Pulmonic region 3. ​Tricuspid valve region 4. ​Abdomen 5. ​Mitral valve region Question 26 The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? Standard Text: ​Select all that apply. 1. ​Eye response 2. ​Motor response 3. ​Verbal response 4. ​Orientation 5. ​Musculoskeletal response46 Question 27 A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? Standard Text: ​Select all that apply. 1. ​Inspect the abdomen. 2. ​Auscultate the abdomen. 3. ​Palpate the abdomen. 4. ​Assess vital signs. 5. ​Assess peripheral pulses. Question 28 The nurse is assessing the musculoskeletal status of a 4-year-old child. What findings should the nurse consider as being expected in this client? Standard Text:​ Select all that apply. 1. Lordosis 2. Genu valgus 3. Genu varum 4. Pronation of the feet 5. Asymmetric leg abduction Question 29 The nurse is concerned that an older client has nutritional deficiencies. What did the nurse find when assessing this client’s nails to make this clinical decision? Standard Text: ​Select all that apply.47 Chapter 44 Kozier & Erb’s ​Fundamentals of Nursing​, 10/E Chapter 44 Question 1 The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the client’s legs when turning? Standard Text: Select all that apply. 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg Question 2 During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. ​Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. ​Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. ​Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. ​The pregnant woman’s exercise should actually increase above normal recommended levels to prevent water weight gain. Question 348 The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. ​Institute an exercise plan that includes weight-bearing activities. 2. ​Increase the amount of calcium in the client’s diet. 3. ​Protect the client’s bones with strict bed rest. 4. ​Provide the client with assisted range-of-motion exercising twice daily. Question 4 The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client’s plan of care? 1. ​Frequent position changes to reverse the contractures 2. ​Exercises to strengthen flexor muscles 3. ​Range-of-motion exercises to prevent worsening of contractures 4. ​Weight-bearing activities to stimulate joint relaxation Question 5 The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. ​Decrease in blood pressure when moving from supine to standing 2. ​Decrease in heart rate when moving from supine to sitting 3. ​Pale color in the legs when lying in bed 4. ​Complaints of dizziness when first sitting up Question 649 The client’s chief complaint is, “I just can’t get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired.” Which nursing diagnosis is most likely appropriate for this client? ​Activity Intolerance: 1. ​Level 1. 2. ​Level 2. 3. ​Level 3. 4. ​Level 4. Question 7 The nurse is considering using the NANDA nursing diagnosis ​Impaired Physical Mobility​ in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. ​Include what mobility is impaired. 2. ​Use Level 1, 2, 3, or 4 to describe immobility. 3. ​Describe what happens when the client attempts mobility. 4. ​Add strength assessment data. Question 8 The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. ​Nurses must wear back belts when lifting clients. 2. ​All nursing personnel must attend annual body mechanics education. 3. ​In order to prevent injury, nurses must strive to become physically fit. 4. ​No solo lifting of clients is permitted in the facility. Question 950 The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. ​Place the feet together to provide a strong base of support. 2. ​Flex the knees to lower the center of gravity. 3. ​Face the box, pick it up, and rotate the upper body toward the table. 4. ​Hold the box as close to the body as possible. Question 10 The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. ​High Fowler’s position with two pillows behind the head 2. ​Orthopneic position across the overbed table 3. ​Prone position with knees flexed and arms extended 4. ​Sims position with both legs flexed Question 11 While assisting the client with a bath, the nurse encourages full range of motion in all the client’s joints. Which activity would best support range of motion in the hand and arm? 1. ​Give the client a washcloth to wash the face. 2. ​Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. ​Have the client brush the hair and teeth. 4. ​Move each of the client’s hand and arm joints through passive range of motion. Question 12 The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse?51 1. ​Deeply palpate the area for rebound tenderness. 2. ​Percuss over the area for change in tone. 3. ​Measure the calf and compare to the opposite calf. 4. ​Medicate the client for pain and reassess in 30 minutes. Question 13 The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. ​Percuss for flatness over the liver. 2. ​Palpate for bladder fullness. 3. ​Use the p.r.n. order to medicate the client with an antacid. 4. ​Inspect the sacral area for edema. Question 14 The client who is unconscious is developing foot drop. What nursing action is indicated? 1. ​Place high-topped shoes on the client while in bed. 2. ​Keep the linens on the end of the bed turned back to expose the feet. 3. ​Use only the prone and Sims positions for client positioning. 4. ​Use a device to elevate the linens off the feet. Question 15 The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Standard Text: Select all that apply. 1. ​Place a turn sheet on the bed.52 2. ​Always use two personnel to move the client. 3. ​Stand at the head of the bed to pull the client up. 4. ​Slide the client toward the head of the bed. 5. ​Encourage the client to assist as possible. Question 16 The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. ​Perform hand hygiene. 2. ​Move the client to the side of the bed. 3. ​Place the client’s arm over the chest. 4. ​Raise the opposite side rail. Question 17 When planning care, the nurse should identify which client as needing logrolling for position changes? 1. ​A client with documented pneumonia 2. ​The client who has had abdominal surgery 3. ​The client who fell from a house, sustaining a fractured tibia 4. ​A client who has a severe headache from hypertensive crisis Question 18 The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. ​Toward the nearest corner of the head of the bed53 2. ​Toward the side of the bed 3. ​Toward the far corner of the foot of the bed 4. ​Directly toward the client Question 19 What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. ​Place the bed in its lowest position. 2. ​Place the wheelchair parallel to the bed. 3. ​Lock the brakes on the bed. 4. ​Place a transfer belt on the client. Question 20 The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. ​slightly higher. 2. ​slightly lower. 3. ​at the same height. 4. ​at least 2 inches lower. Question 21 The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. ​The UAP 2. ​A licensed practical (vocational) nurse54 3. ​A registered nurse 4. ​It makes no difference Question 22 The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurse’s most important action? 1. ​Ensure the client’s modesty as she falls. 2. ​Be certain the client does not hit the head on anything. 3. ​Call for immediate assistance. 4. ​Check the vital signs and for excessive vaginal bleeding. Question 23 The nurse is providing range-of-motion exercising to the client’s elbow when the client complains of pain. What action should the nurse take? 1. ​Stop immediately and report the pain to the client’s physician. 2. ​Discontinue the treatment and document the results in the medical record. 3. ​Reduce the movement of the joint just until the point of slight resistance. 4. ​Continue to exercise the joint as before to loosen the stiffness. Question 24 The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Standard Text: Select all that apply. 1. ​Hot baths 2. ​Heavy meals55 3. ​Use of a rocking chair 4. ​Moving in bed 5. ​Bending down to the floor Question 25 The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

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