Which age-related change should the nurse consider when
formulating a plan of care for an older adult?
Increased sensitivity to glare & diminished sensation of pain
A nurse is caring for a client on bed rest. How can the nurse
help prevent a pulmonary embolus?
Teach the client how to exercise the legs.
What are the clinical indicators that a nurse expects when
an intravenous (IV) line has infiltrated?
Pallor, edema, decreased flow rate
A client with hemiplegia is staring blankly at the wall and
reports feeling like half a person. What is the most
appropriate initial nursing action?
Offer to spend more time with the client.
A nurse is preparing to administer an ophthalmic medication
to a client. What techniques should the nurse use for this
procedure?
Clean the eyelid and eyelashes, apply clean gloves before beginning of
procedure, Press on the nasolacrimal duct after instilling the solution
A nurse must establish and maintain an airway in a client
who has experienced a near-drowning in the ocean. For
which potential danger should the nurse assess the client?
Pulmonary edema
,
What are the best ways for a nurse to be protected legally?
Provide care within the parameters of the state's nurse practice act, document
consistently and objectively, Clearly document a client's non-adherence to the
medical regimen
A nurse is explaining the nursing process to a nursing
assistant. Which step of the nursing process should include
interpretation of data collected about the client?
Evaluation
A client has received instructions to take 650 mg aspirin
(ASA) every 6 hours as needed for arthritic pain. What
should the nurse include in the client's medication teaching?
Take the aspirin with meals or a snack, Do not chew enteric-coated tablets,
Report persistent abdominal pain
When reviewing a drug to be administered, the nurse
identifies that the package insert indicates that the Z-track
injection technique should be used. Under what
circumstance does the nurse expect that this technique will
be necessary?
Medication is irritating to subcutaneous tissue and skin.
Which drug requires the nurse to monitor the client for signs
of hyperkalemia?
Spironolactone (Aldactone)
,A nurse is caring for a client admitted with cardiovascular
disease. During the assessment of the client's lower
extremities, the nurse notes that the client has thin, shiny
skin, decreased hair growth, and thickened toenails. The
nurse understands that this may indicate:
Arterial Insufficiency
What should the nurse include in dietary teaching for a
client with a colostomy?
The diet should be adjusted to include foods that result in manageable stools
A nurse is reviewing a plan of care for a client who was
admitted with dehydration as a result of prolonged watery
diarrhea. Which prescription should the nurse question?
Parenteral albumin (Albuminar)
A hospitalized client experiences a fall after climbing over
the bed's side rails. Upon reviewing the client's medical
record, the nurse discovers that restraints had been
prescribed but were not in place at the time of the fall. What
information should the nurse include in the follow-up
incident report?
A listing of facts related to the incident as witnessed by the nurse
The nurse recognizes that what is the reason the faucets on
the sinks in a client's room are considered contaminated?
They are touched by dirty hands when turning the water on.
, The nurse is teaching a client about adequate hand hygiene.
What component of hand washing should the nurse include
that is most important for removing microorganisms?
Friction
When meeting the unique preoperative teaching needs of an
older adult, the nurse plans a teaching program based on
the principle that learning:
Requires continued reinforcement
A graduate nurse is preparing to apply to the State Board of
Nursing for licensure to practice as a licensed practical
nurse. What group primarily is protected under the
regulations of the practice of nursing?
The public
The nurse is discussing discharge plans with a client who
had a myocardial infarction. The client states, "I'm worried
about going home." The nurse responds, "Tell me more
about this." What interviewing technique did the nurse use?
Exploring
A nurse suspects that a client has poison ivy. Assessment
findings reveal vesicles on the arms and legs. A vesicle can
be described as:
A lesion filled with serous fluid
The nurse is preparing discharge instructions for a client
who has begun to demonstrate signs of early Alzheimer's
formulating a plan of care for an older adult?
Increased sensitivity to glare & diminished sensation of pain
A nurse is caring for a client on bed rest. How can the nurse
help prevent a pulmonary embolus?
Teach the client how to exercise the legs.
What are the clinical indicators that a nurse expects when
an intravenous (IV) line has infiltrated?
Pallor, edema, decreased flow rate
A client with hemiplegia is staring blankly at the wall and
reports feeling like half a person. What is the most
appropriate initial nursing action?
Offer to spend more time with the client.
A nurse is preparing to administer an ophthalmic medication
to a client. What techniques should the nurse use for this
procedure?
Clean the eyelid and eyelashes, apply clean gloves before beginning of
procedure, Press on the nasolacrimal duct after instilling the solution
A nurse must establish and maintain an airway in a client
who has experienced a near-drowning in the ocean. For
which potential danger should the nurse assess the client?
Pulmonary edema
,
What are the best ways for a nurse to be protected legally?
Provide care within the parameters of the state's nurse practice act, document
consistently and objectively, Clearly document a client's non-adherence to the
medical regimen
A nurse is explaining the nursing process to a nursing
assistant. Which step of the nursing process should include
interpretation of data collected about the client?
Evaluation
A client has received instructions to take 650 mg aspirin
(ASA) every 6 hours as needed for arthritic pain. What
should the nurse include in the client's medication teaching?
Take the aspirin with meals or a snack, Do not chew enteric-coated tablets,
Report persistent abdominal pain
When reviewing a drug to be administered, the nurse
identifies that the package insert indicates that the Z-track
injection technique should be used. Under what
circumstance does the nurse expect that this technique will
be necessary?
Medication is irritating to subcutaneous tissue and skin.
Which drug requires the nurse to monitor the client for signs
of hyperkalemia?
Spironolactone (Aldactone)
,A nurse is caring for a client admitted with cardiovascular
disease. During the assessment of the client's lower
extremities, the nurse notes that the client has thin, shiny
skin, decreased hair growth, and thickened toenails. The
nurse understands that this may indicate:
Arterial Insufficiency
What should the nurse include in dietary teaching for a
client with a colostomy?
The diet should be adjusted to include foods that result in manageable stools
A nurse is reviewing a plan of care for a client who was
admitted with dehydration as a result of prolonged watery
diarrhea. Which prescription should the nurse question?
Parenteral albumin (Albuminar)
A hospitalized client experiences a fall after climbing over
the bed's side rails. Upon reviewing the client's medical
record, the nurse discovers that restraints had been
prescribed but were not in place at the time of the fall. What
information should the nurse include in the follow-up
incident report?
A listing of facts related to the incident as witnessed by the nurse
The nurse recognizes that what is the reason the faucets on
the sinks in a client's room are considered contaminated?
They are touched by dirty hands when turning the water on.
, The nurse is teaching a client about adequate hand hygiene.
What component of hand washing should the nurse include
that is most important for removing microorganisms?
Friction
When meeting the unique preoperative teaching needs of an
older adult, the nurse plans a teaching program based on
the principle that learning:
Requires continued reinforcement
A graduate nurse is preparing to apply to the State Board of
Nursing for licensure to practice as a licensed practical
nurse. What group primarily is protected under the
regulations of the practice of nursing?
The public
The nurse is discussing discharge plans with a client who
had a myocardial infarction. The client states, "I'm worried
about going home." The nurse responds, "Tell me more
about this." What interviewing technique did the nurse use?
Exploring
A nurse suspects that a client has poison ivy. Assessment
findings reveal vesicles on the arms and legs. A vesicle can
be described as:
A lesion filled with serous fluid
The nurse is preparing discharge instructions for a client
who has begun to demonstrate signs of early Alzheimer's
