A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide?
... [Show More] Use a douche preparation no more than once a month. Increase daily intake of fiber and leafy green vegetables.
Select nylon underwear that is loose-fitting, white, and comfortable.
Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer?
Notify the healthcare provider if heavy vaginal discharge occurs. Use condoms for sexual intercourse during the next week.
Flat subclinical mucosal lesions are a common harmless side effect.
Use a sanitary napkin instead of a tampon.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?"
Morbidly obese. Markedly obese.
Inadequate lifestyle changes in diet and exercise.
Increased morbidity and mortality risks.
A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?
"It allows you to document your wishes regarding life-sustaining treatment if you can't speak for yourself."
"It will identify someone that can make decisions for your health care if you are in a coma or vegetative state."
"It is not legally binding, but helps the healthcare provider know exactly what medical treatments you want."
"It is a form that all people must sign before admission to the hospital so that individualized treatment plans can be developed."
Which approach should the nurse use when preparing a toddler for a procedure?
Demonstrate the procedure using a doll. Avoid asking the child to make choices.
Plan a teaching session to last about 20 minutes. Show equipment but prevent child from handling it.
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan?
Apply warm compresses to reduce swelling. Wear sunglasses to protect eyes from sunlight.
Take acetaminophen (Tylenol) for any eye discomfort.
Avoid sharing towels and washcloths with siblings.
The scope of professional nursing practice is determined by rules promulgated by which organization?
State's Board of Nursing.
State Nursing Associations.
American Nurses Association (ANA).
National Labor Relations Board (NLRB).
A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?
Administer thiamine (B1) to prevent Korsakoff's syndrome.
Monitor for increased blood pressure and pulse.
Administer a PRN benzodiazepine as needed for anxiety. Encourage fluid intake of non-caffeinated beverages.
Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?
Ability to grasp objects. Ability to bear weight.
Upper body muscle strength.
Tolerance of exertion.
A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid?
Dried prunes.
Cottage cheese. Mashed potatoes. Mustard greens.
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?
A pregnant woman.
A teenager beginning puberty. A 3-month-old infant.
A school-aged child.
When documenting assessment data, w hich statement should the nurse record in the narrative nursing notes?
Hair is within normal limits.
Most all permanent teeth are present.
S1 murmur auscultated in supine position. Slight tenderness in the left upper quadrant.
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
Administer the dose as prescribed.
Withhold the drug and notify the healthcare provider. Give intravenous (IV) calcium gluconate.
Recheck the vital signs in 30 minutes and then administer the dose.
Rationale
Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so the drug should be administered, based on the client's heart rate and blood pressure.
During a client assessment, the client says, "I can’t walk very well." Which action should the nurse implement first?
Choose the most successful approach.
Identify the problem. Consider alternatives.
Predict the likelihood of the outcome.
A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having?
Obsessive.
Phobic.
Delusional. Paranoid.
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
Initiate the lactation process. Prevent neonatal hypoglycemia.
Stimulate contraction of the uterus. Facilitate maternal-infant bonding.
Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse?
Serves as a consultant to businesses and management. Implements health programs for construction workers.
Designs quality improvement methods that measure health outcomes. Conducts research studies that enhance health safety.
Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia?
Mental retardation.
Rigid extension of all extremities.
Lethargy or irritability.
Increased or unstable temperature.
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
Pindolol (Visken). Carteolol (Ocupress).
Metoprolol tartrate (Lopressor).
Propranolol hydrochloride (Inderal).
During the physical assessment, which finding should the nurse recognize as a normal finding?
Regular pulsation at the epigastric area when the client is supine.
Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds. Jugular venous pressure palpable with the client in an upright position.
Point of maximal impulse at the third intercostal space in the right midclavicular line.
A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?
Stop the code immediately.
Continue the code according to protocol.
Ask the legal department if the code should be continued. Assess the family's support for the durable power of attorney.
After eye drops are instilled, which instruction should the nurse provide to the client?
"Tilt your head back." "Look to each side."
"Close your eyelids." "Blink quickly 3 times."
A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client?
Rebreather mask. Venturi mask.
Nasal cannula.
Hand-held nebulizer.
When engaging in planned change on the unit, what should the nurse-manager establish first?
Goals for achieving the change are established.
Options for accomplishing the change are explored. Resources needed for the change are available.
Staff members are aware of the need for change.
The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?
Suction for only 5 seconds since the client has only one lung and cannot hold his breath for very long.
Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning.
Have another person available to hold the client's hands to prevent inadvertent removal of the suction tube.
Suction deeply and vigorously to ensure that all secretions are removed in order to prevent atelectasis.
An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?
Stage 1.
Stage 2.
Stage 3.
Stage 4.
The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding?
Purplish-red pinpoint lesions of the skin. Purple to bluish discoloration of the skin.
Small circumscribed elevations containing purulent fluid. Generalized reddish discoloration of an area of skin.
After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?
The client who has a new onset of difficult breathing.
An anxious client who is 3 days post myocardial infarction.
The client with type 2 diabetes mellitus who has a call light on. A client whose blood transfusion is near completion.
The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?
A Hispanic client may have inward-turned eyelashes. An Asian client may have a horizontal palpebrale fissure.
An African-American client may have slightly yellow sclerae.
A Caucasian client may have a slightly protruding eyeball.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?
Team nursing.
Primary nursing.
Case management.
Functional nursing.
A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map?
Nurse-manager group. Multidisciplinary group.
Single-discipline group. Surgical staff group.
A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse?
Repeat the skin test and chest radiograph in three weeks.
Administer isoniazid (INH) daily for 6 to 9 months.
Give combination therapy of antitubercular drugs for 6 months.
Recommend the bacille Calmette-Gu rin (BCG) vaccine.
A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide?
Low doses of tamoxifen prevent menopausal hot flashes.
An option used to reduce the risk of breast cancer for all women.
This anti-estrogen drug inhibits malignancy growth.
Part of a combination of chemotherapeutic agents used to treat tumors.
The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices?
Income grouping. Ethic background.
Individual beliefs. Educational level. [Show Less]