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1. a nurse is admitting a client who a) establish client outcomes
will undergo a craniotomy. During The planning phase includes developing goals and out-
the planning phase of the nursing comes that help the nurse create the client's plan of
process, which of the following ac- care.
tions should the nurse take?
a) establish client outcomes The nursing process:
b) collect information about past step 1. assessment phase- collect information about
health problems past health problems (vitals, age, height)
c) determine whether the client step 2. analysis phase- identify the client's specific health
has met specific goals problem
d) identify the client's specific step 3. planning phase- establish client goals and out-
health problem comes and selects interventions that will help to achieve
them. Also involves setting care priorities.
step 4. implementation- provides client care and uses
interpersonal/technical skills when implementing nurs-
ing interventions
step 5. evaluation phase- use critical thinking skills to
determine whether the client has met a specific goal.
examines results, compares the data, identifies errors,
and considers pt's situation
2. a client who reports shortness of b) observe the client's rate, depth, and character of
breath requests the nurse's help respirations
in changing positions. After repo-
sitioning the client, which of the
following actions should the nurse
take next?
a) encourage the client to take
deep breaths
b) observe the client's rate, depth,
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and character of respirations
c) prepare to administer oxygen
d) give the client a backrub to pro-
mote relaxation
3. a nurse is collecting health history b) pace speech to allow time for the interpreter to convey
data from a client who is deaf and the words
uses American sign language(ASL)
to communicate. The nurse will
be working with an ASL inter-
preter. Which of the following ac-
tions should the nurse take when
working with the interpreter?
a) face away from the client to
avoid distractions
b) pace speech to allow time
for the interpreter to convey the
words
c) make eye contact with the inter-
preter when explaining the proce-
dure
d) stand in the background while
the interpreter translates the mes-
sage
4. a nurse manager is providing d) infection acquired from diagnostic procedure
teaching to a group of newly li- Iatrogenic HAIs directly result from diagnostic or thera-
censed nurses about the ways peutic procedures
that clients acquire healthcare-as-
sociated-infections (HAI's). Which
of the following routes of infection
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should the manager identify as an
iatrogenic HAI?
a) infection required from improp-
er hand hygiene
b) infection acquired by drug resis-
tance
c) infection acquired by inappro-
priate waste disposal
d) infection acquired from diag-
nostic procedure
5. a nurse is caring for a client who a) wear gloves when changing the clients gown
has Clostridium difficile infection
and is in contact isolation. Which -alcohol-based sanitizers are ineffective against the
of the following actions should thespores of C.difficile
nurse take? -nurse should wear a mask when working within 3 ft of
a patient with droplet precautions
a) wear gloves when changing the -the nurse should not place the client on complete bed
clients gown rest because this places him at risk for the hazards of
b) use alcohol-based sanitizers to immobility, such as impaired skin integrity and retained
cleanse the hands respiratory secretions. The nurse should instruct the pa-
c) wear a mask when assisting the tient to stay in his room but to move, cough, and deep
client with his meal tray breathe at least every 2 hours
d) place the client on a complete
bed rest
6. a nurse is reviewing the use of side c) "if the client seems confused, I'll raise all 4 side rails
rails with an A.P. Which of the fol- so that he doesn't hurt himself"
lowing statements by the A.P indi-
cates that further teaching is re-
quired?
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a) "I should not leave all 4 side rails
up unless there is a prescription
for restraints"
b) "an alert client will be the safest
if I raise the 2 upper side rails at
the head of the bed"
c) "if the client seems confused,
I'll raise all 4 side rails so that he
doesn't hurt himself"
d) "if a client is sedated, I should
raise all 4 side rails to prevent a fall
out of bed"
7. which diseases have airborne pre- Varicella, TB, and measles
cautions?
8. which diseases have contact pre- C.diff, MRSA, scabies, vancomycin resistant enterococci
cautions?
9. which diseases have droplet pre- rubella, influenza, meningoccal, pneumonia, strepto-
cautions? coccal pharyngitis
10. A nurse in a provider's office is a) osteoporosis
measuring a client & notes a A loss of height is often an early indication of osteoporo-
loss in height from the previous sis with occurs due to a loss of calcium in the vertebrae
year. The nurse should identify which can cause them to fracture and collapse.
this finding as a manifestation
of which of the following muscu- - scoliosis does not precipitate a decrease in the height
loskeletal system disorders? of the client. It is an abnormal lateral curve of the sign
a) osteoporosis - kyphosis does not precipitate a decrease in the height
b) scoliosis of a client. It is an exaggerated posterior curvature of the
thoracic spine hunchback