Study Guide Exam 5 EAQ PDF

**[Study Guide Exam 5]** Top of Form Which assessment should the nurse complete immediately after hearing the client choked while eating? a. The caregiver\'s knowledge about feeding a person who is dysphagic. b. Auscultate the client\'s lungs for adventitious breath sounds. c. Assess clients...

**[Study Guide Exam 5]** Top of Form Which assessment should the nurse complete immediately after hearing the client choked while eating? a. The caregiver\'s knowledge about feeding a person who is dysphagic. b. Auscultate the client\'s lungs for adventitious breath sounds. c. Assess clients level of consciousness. d. Determine the client\'s ability to swallow liquids. Bottom of Form Top of Form After the client assessment is complete, what does the nurse determine is the BEST course of action? a. Report the assessment findings to the health care provider. b. Elevate the head of the clients bed to 45 degrees and instruct spouse to leave it elevated. c. Inform the spouse to give the client acetaminophen. d. Provide directions on how to properly feed a person with dysphagia to the spouse. Bottom of Form Top of Form During the admission procedure, what is the nurse\'s responsibility regarding advance directives? a. Determine if the client has completed a Living Will and a durable power of attorney for healthcare (DPAHC). b. Explain that the Patient Self-Determination Act (PSDA) requires a living will. c. Instruct client\'s spouse to have the client sign a Living Will when she is no longer disoriented. d. Ask the client\'s spouse if they would like to make any changes. Bottom of Form Top of Form The nurse assures the spouse that the physicians and staff will make every effort to keep the client comfortable. After making sure the client and her spouse are settled and do not require anything further at this time, what action should the nurse take? a. Document that the client is aware of the Patient Self-Determination Act. b. Place a copy of the Living Will in the medical record and document its presence. c. Notify the HCP that the spouse desires euthanasia for the client. d. Report to the charge nurse the spouse seems to be in denial about the seriousness of the client\'s condition. Top of Form What is the nurse\'s best response? a. \"How was she positioned when you fed her?\" b. \"Saliva entering the lungs can also cause pneumonia. And you did not have a way of knowing she was aspirating.\" c. \"You know you did the best you could.\" d. \"We know it was not intentional on your part.\" Bottom of Form Top of Form Which response demonstrates that the nurse understands the underlying premise of a Living Will? a. \"We will honor the directives in her Living Will.\" b. \"Are you sure that this is what you really want for the client?\" c. \"Your healthcare providers want to do all they can to preserve life.\" d. \"Have you spoken to your faith leader about the client\'s wishes?\" Bottom of Form Top of Form Which nursing intervention should be implemented to care for the client\'s mouth? a. Give her sips of water through a straw. b. Offer her an ounce of ice chips every hour. c. Provide mouth care daily with her bath. d. Clean her mouth frequently with oral swabs. Bottom of Form Top of Form What intervention should the nurse implement? a. Suction tracheal secretions. b. Suction oral secretions from mouth and throat. c. Encourage deep breathing every hour while awake. d. Teach the client how to use an incentive spirometer. Bottom of Form Top of Form What is the best response by the nurse? a. \"Yes, this is the hospice unit of the hospital.\" b. \"It must be difficult to see the changes in your mother.\" c. \"Why are you angry at the nurses and other healthcare providers?\" d. \"You are in the stage of denial in the grief process.\" Bottom of Form Top of Form How should the nurse respond to the family\'s request? a. Ask the family what purpose she thinks massage will serve. b. Inform family must produce the therapist\'s credentials first. c. Inform the family massage therapists are welcome in the hospice unit. d. Share with the family the nurse uses alternative therapies themselves. Top of Form According to the Kubler-Ross Model, how should the nurse categorize this stage of grief being exemplified by the adolescent\'s statements? a. Acceptance. b. Depression. c. Bargaining. d. Denial. Bottom of Form Top of Form What is the best response by the nurse? a. Tell the family to take the child to a grief counselor immediately. b. Call the family\'s faith leader to get information that is culturally appropriate. c. Recommend their child\'s questions be answered honestly in simple terms. d. Ask to speak to the child to assess what is really bothering him. Bottom of Form Top of Form Which phrase should the nurse recommend? a. \"She went to sleep and didn\'t wake up.\" b. \"She died and that makes us feel very sad.\" c. \"God wanted her because she was so good.\" d. \"We\'ve lost her and will miss her very much.\" Bottom of Form Top of Form What information regarding the medication order should the nurse provide to the client\'s spouse? (Select all that apply. One, some, or all options may be correct.) Select all that apply a. This route is least likely to produce drug addiction. b. There is no other route by which to give this medication. c. The medication is rapidly absorbed and acts quickly. d. This route decreases the chance of aspiration. e. Risk for respiratory depression is lessened using this route. Bottom of Form Top of Form Fill in the blank How many milliliters of medication will the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)  First, convert client\'s weight from pounds to kilograms: 88/2.2 = 40 kg\ Next, calculate how many mg she should receive: 0.2 mg/kg times 40 kg: 0.2 × 40 = 8 mg\ To calculate the amount to draw up in the dropper:\ D = dose ordered or desired dose (8 mg)\ H = dose on container label or dose on hand (20 mg)\ V = form and amount in which drug comes (tablet, capsule, liquid) (1 mL)\ [8 mg] x 1 mL = 0.4 mL\ 20 mg Bottom of Form Top of Form Which action should the nurse choose to implement? a. Take the vital signs as prescribed. b. Stand quietly until the prayer is over. c. Express discomfort by leaving the room. d. Ask the faith leader to come back later to pray. Bottom of Form Top of Form What is the best response to support the client and her spouse spiritually? a. \"Do you have any wishes I should convey to the staff?\" b. \"I wish my faith were as strong as yours.\" c. \"Does your family share your faith?\" d. \"Would you like to visit the chapel on the first floor?\" Bottom of Form Top of Form What feedback from the nurse will encourage the spouse to elaborate more about feelings? a. Praise the couple for being able to stay married so long. b. Ask the spouse to share memories of the couple\'s time together. c. Remark they are role models for the faith community. d. Share the memories of own family. Bottom of Form Top of Form To assist the client and family in life review, what is the best intervention by the nurse? a. Encourage visitors to talk quietly so the client is not disturbed. b. Suggest to the family that they bring photo albums to show the client. c. Encourage the client and family to talk about their experiences. d. Encourage visitors to use touch when communicating with the client. Top of Form Which other physical symptom should the nurse anticipate?\ a. Hyperreflexia in legs and arms. b\. Increased urinary output. c\. Mottling of hands and feet. d\. Head turned away from light. Bottom of Form Top of Form Based on the assessment findings, what action should the nurse implement? a. Inform the family member that her mom\'s condition is worsening. b. Suggest that the daughter tell her father to rush back to the hospital immediately. c. Hold the family member\'s hand, but do not disclose the client\'s vital signs. d. Notify the family that the client will probably die today. Bottom of Form Top of Form How should the nurse respond? a. \"Do you think you are strong enough?\" b. \"Yes. I would be happy to watch you.\" c. \"I am not sure that is a good idea.\" d. \"I think there is a policy against it.\" Bottom of Form Top of Form How should the nurse respond? a. Instruct the family and the religous leader to leave the room. b. Remain available to assist the women of the religous community as needed. c. Tell the religous leader that postmortem care must be done by the hospice staff regardless of religion. d. Remind the family that an autopsy must be performed before the burial. Top of Form Which statement is the **best** description of the sleep pattern for a normal adult? a. Sleep problems decrease in middle-aged adults. b. Most of the sleep cycle is made up of rapid eye movement (REM) sleep. c. An adult has four to six sleep cycles, each with non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep, during a normal night\'s sleep. d. A middle-aged adult requires less sleep than an elderly adult. How does the nurse respond to the client's disclosure that he used his spouse's diazepam tablets to help him sleep? a. "Do not take more of the diazepam than is prescribed." b. "You should not take someone else's prescription." c. "Let me note that in your chart." d. "Anti-anxiety medication can help you relax enough to fall asleep." Which response by the nurse is **most** appropriate? a. \"You may resume the temazepam if you still have the prescription.\" b. \"You really don\'t need a medication like this, do you?\" c. \"You should be reevaluated by a healthcare provider before resuming this medication.\" d. \"Absolutely not! This type of drug is very addictive and should be avoided whenever possible.\" The nurse performs a focused assessment on the client, before he sees the healthcare provider (HCP). As part of the assessment, the nurse evaluates the client for which additional symptoms that are commonly associated with sleep deprivation? (Select all that apply.) Select all that apply a. Nocturia. b. Tachycardia. c. Euphoria. d. Sleep apnea. Which statements reflect potential expected outcomes for the nursing problem \"disturbed sleep pattern related to stress from new job\"? (Select all that apply.) Select all that apply a. Client can identify ways to relieve stress during the day and before bedtime. b. Client will report a 50% decrease in night awakenings within 1 week. c. Client establishes bedtime rituals, such as having a glass of wine before bed. d. Client maintains a sleep/wake log for 1 month. Which interventions should the nurse add to the client\'s plan of care? (Select all that apply.) Select all that apply a. Encourage an increase in carbohydrates and move the evening meal to 1 hour before bedtime to promote sleep. b. Monitor bedtime food and beverage intake, which might interfere with sleep. c. Instruct the client to keep reading material from work at the bedside to review when he awakens. d. Instruct the client to get out of bed if unable to fall back to sleep within 30 minutes and to do a quiet activity until becoming sleepy. e. Suggest the use of a soft, conforming mattress and pillow set for better body alignment. Which is the **best** explanation by the nurse for educating the client about OSA? a. There is a lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep. b. There is a dysfunction of mechanisms that regulate the sleep and wake states, causing excessive sleepiness during the day. c. The airway remains open, but the brain fails to send messages to the diaphragm and chest muscles to initiate respirations. d. It is a syndrome characterized by chronic difficulty falling asleep with frequent awakenings at night. The nurse considers which information to be subjective data? (Select all that apply.) Select all that apply a. Client states he only sleeps 3 or 4 hours per night. b. The client displays irritable behavior in front of the nurse, and yells at his wife when she points out he is irritable. c. The client has gained an additional five pounds. d. The client reports that the CPAP apparatus is uncomfortable. e. The client\'s wife states he has been yawning a lot at home. The charge nurse should assign the client to which room? a. A semi-private room with another client. b. A designated isolation room with a double door. c. A private room near the nursing station and report room. d. A private room at the end of the hall. To promote sleep for a hospitalized client, which intervention should the nurse implement? a. Avoid performing the prescribed assessments every 4 hours during the night. b. Withhold the client\'s pain medication during the day to decrease napping episodes. c. Ensure that the client\'s room is kept completely dark during the night with no outside lighting. d. Close the door to the client\'s room whenever possible to decrease the noise level and light coming into the room. Which **priority** action should the nurse implement? a. Quietly place an oxygen mask on the client without waking him. b. Gently shake the client to awaken him. c. Document the observation as an expected finding. d. Request that the HCP to reevaluate the client\'s status. How should the nurse proceed? a. Administer the PRN medication. b. Administer oxygen via facemask. c. Explain the oxygen saturation level is too low and that it wouldn't be safe. d. Administer half of the prescribed dose. Which action should the nurse implement? a. Document this expected finding. b. Contact the HCP about this abnormality. c. Recommend the application of a cardiac monitor. d. Increase vital sign monitoring from every 8 hours to every 4 hours. In managing the client\'s postoperative care, which task should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) Select all that apply a. Complete a focused respiratory assessment every 4 hours. b. Obtain pulse oximetry and respiratory rate every 2 hours. c. Take vital signs and complete body systems assessment every 8 hours. d. Administer prescribed throat lozenges every 2 hours as needed. e. Serve the prescribed breakfast tray to the client. Which observation should be documented in the nurse's assessment? (Select all that apply.) Select all that apply a. Observe for excessive drainage. b. Measure oxygen saturation. c. Determine skin turgor. d. Measure the tympanic temperature. e. Blood glucose level. Which is the **most** important action for the nurse to implement? a. Honor the spouse\'s request and leave the medication capsule at the bedside. b. Wake the client and administer the first dose of the antibiotic. c. Let the client sleep for 1 more hour and return with the antibiotic. d. Allow the client to start the medication at home after discharge. Fill in the blank The client has been prescribed levoflloxacin 750 mg PO daily. The nurse has received 250 mg tablets from the pharmacy. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the whole number.)  Using the formula method: D/H × Q = X\ \ 750 mg divided by 250 mg × 1 = 3.\ Three 250 mg tablets = 750 mg. How should the nurse respond to the client\'s statement? a. \"Right now you need to concentrate on getting better.\" b. \"I will have a social worker call you to see if you need any financial help.\" c. \"You seem concerned about missing work and the pressures of your job.\" d. \"I know what you mean. I couldn\'t afford to miss very much work either.\" Which is the **most** effective method to evaluate improvement of the client\'s OSA? a. Ask the client how he has been sleeping for the last 2 weeks since surgery. b. Obtain current vital signs, including a pulse oximetry reading. c. Ask the client\'s spouse about the client's snoring and respiratory pattern at night. d. Assess lung sounds in the sitting and supine position. Which initial response by the nurse is **best**? a. \"Please tell me about your son\'s sleep habits.\" b. \"Don\'t worry, it is normal for teenagers to sleep a lot. You are just hypersensitive about sleep.\" c. \"Teens typically do not need as much sleep as adults, so there must be a problem.\" d. \"You seem overly concerned about your son. You need to worry about yourself now.\" Which response by the nurse is accurate? a. \"Sleeping until noon is unhealthy for anyone no matter what age they are.\" b. \"Many adolescents start developing this type of pattern as they develop independence.\" c. \"I would try enforcing a strict, earlier bedtime routine so he does not sleep so late.\" d. \"Excessive daytime sleepiness is symptomatic of the sleep disorder narcolepsy.\" Top of Form Which information obtained by the nurse is most likely to influence the client\'s perception of her pain? a. Client's younger child is an infant who feeds every 3 hours. b. Clients 4-year-old enjoys being the \"big brother\" to his baby sister. c. Client was a first grade teacher before having children but now stays home. d. Client's parents live in the same neighborhood and often help with the children. Bottom of Form Top of Form To assess the quality of the client's pain, the nurse would ask which question? a. \"On a scale of 0 to 10, how would you rate your pain?\" b. \"How would you describe the pain you are experiencing?\" c. \"What actions do you take to relieve the pain?\" d. \"When did your pain begin?\" Bottom of Form Top of Form Which behavior does the client exhibit, that the nurse documents as objective signs of acute pain? a. States pain level of 5 out of 10. b. Complains of shortness of breath. c. This behavior is more typical of anxiety caused by pain. d. Frequent grimacing. Bottom of Form Top of Form The nurse would predict what physiological effects of the client\'s pain? (Select all that apply. One, some, or all options may be correct.) Select all that apply a. Tachycardia b. Hyperthermia c. Decreased or slower movement. d. Increased blood pressure. Bottom of Form Top of Form The nurse considers interventions to include in the plan of care. Before implementing any interventions, what action is most important for the nurse to take? a. Place a copy of the plan of care in the client\'s chart. b. Evaluate the client's response to the interventions. c. Review interventions in a care plan manual. d. Discuss the plan of care with the client. Bottom of Form Top of Form Which nursing intervention(s) would the nurse choose to implement to determine the etiology of the client\'s anxiety? (Select all that apply. One, some, or all options may be correct.) Select all that apply a. Refer client to psychologist. b. Continue to interview the client. c. Provide an anxiety screening tool for the client to utilize. d. Obtain client\'s medical history. Bottom of Form Top of Form Which is the best goal for the nurse to include in the plan of care related to the problem statement of \"acute pain related to strain on muscles with movement?\" a. Client reports pain of less than 1 on a 0 to 10 scale. b. Client will verbalize pain control methods. c. Client will learn alternative methods for pain control. d. Client will learn to live with long-term pain. Bottom of Form Top of Form Which medication should the nurse suggest as a common NSAID? a. Diphenhydramine. b. Alprazolam. c. Calcium carbonate. d. Ibuprofen. Bottom of Form Top of Form The nurse should explain medication safety and educate the client about facts regarding ASA and children? a. ASA comes in children\'s doses, which can be given safely to 4-year-old children. b. ASA is associated with Reye\'s syndrome in children. c. All ASA products should be avoided in children unless specifically prescribed. d. It is ok to give half an adult dose of ASA to a child. Bottom of Form Top of Form Which response by the nurse is accurate? a. \"Warm moist compresses are a better choice for new injuries. \" b. \"A heating pad is more effective than moist compresses because it will penetrate more deeply into the muscles.\" c. \"Heating pads provide dry heat, which promotes vasoconstriction, reducing any muscle swelling that has occurred.\" d. \"The dry heat provided by your heating pad will help relieve your pain by promoting muscle relaxation.\" Bottom of Form Top of Form Which instruction is most important for the nurse to provide regarding the client\'s statement? a. The cold pack provides pain relief but does not heal the injury. b. The cold applications should be alternated with the heating pad. c. Cold reduces inflammation and prevents tissue swelling. d. The cold pack should only be applied for approximately 20 minutes at a time. Bottom of Form Top of Form How should the nurse explain the mechanism that causes the skin to become reddened from prolonged exposure to cold? a. Reflex vasodilation occurs following the initial vasoconstricting effects of cold. b. Cold causes a numbing sensation, which interferes with circulation at the site. c. Debris from necrotic tissue collects at the site of vasoconstriction, causing inflammation. d. Intradermal tissue blisters occur as the result of the damage caused by exposure to cold. Bottom of Form Top of Form Which explanation by the nurse best describes the how the TENS unit soothes paint? a. Continuous high-pressure stimulation of the pain nerve fibers are blocked. b. It sends stimulating pulses through the skin, to block pain signals from reaching the brain. c. Electrodes are placed at pressure points to measure biofeedback and reduce stress. d. Needles are inserted to stimulate specific points in the body. Top of Form After the nurse explains how the TENS unit soothes pain, the client wants to know the best way to apply and use the unit. Which instructions should the nurse include? (Select all that apply. One, some, or all options may be correct.) Select all that apply a. After applying the electrodes, set the unit to provide continuous stimulation. b. Place the electrodes directly over the site of pain. c. Make sure the equipment is not damaged in anyway. d. Make sure the unit is set to the prescribed level. e. It does not matter if you have any pain cream or lotions on the site. Bottom of Form Top of Form What is the rationale for scheduled drugs needing specific protocols? a. Large doses can be fatal. b. Respiratory depression can occur. c. There is a potential for abuse. d. Tolerance develops with repeated use. Bottom of Form Top of Form What action should the nurse implement? a. Request that the oncoming nurse investigate the inaccurate count, and leave a written report for the first nurse. b. Complete a variance report, documenting that the count was inaccurate, and submit the report to the pharmacist. c. Review prescriptions for any scheduled drugs with all nurses with access to the medications to determine why the count is inaccurate. d. Schedule a meeting with the medical director of the clinic to discuss methods to reduce drug errors by the nursing staff. Bottom of Form Top of Form Fill in the blank. While the client is in the ED, the HCP prescribes an intramuscular injection of 30 mg of ketorolac, a nonsteroidal anti-inflammatory agent. The medication comes in a preloaded syringe labeled \"20 mg/mL.\" How many mL should the nurse expect to administer? (Enter the numerical value only. If rounding is necessary, round to the tenth.)  20 mg/1 mL = 30 mg/x\ 20x = 30 mL\ x = 1.5 mL Bottom of Form Top of FormSince the client is fairly thin, which site would the nurse choose for the injection? a. Back of the arm. b. Ventrogluteal. c. Dorsogluteal d. Abdomen, 2 inches from the umbilicus. Top of Form To administer the injection the nurse will first place the palm of the hand on which anatomical spot to locate the appropriate injection site? a. The upper outer quadrant of the buttock. b. The anterosuperior iliac spine. c. The greater trochanter. d. The iliac crest. Bottom of Form Top of Form Which actions should the nurse perform when administering an IM (Intermuscular) injection? (Select all that apply. One, some, or all options may be correct.) Select all that apply a. Observe for a small bleb around the tip of the needle. b. Utilize the Z-track method. c. Slowly inject the medication into the muscle mass. d. Follow the facility policy regarding aspiration of IM injection. Bottom of Form Top of Form To ensure that the exercise is most effective, what action should the nurse implement? a. Help the client cross her legs in a semi-yoga position. b. Encourage the client to lie down rather than sit in a chair. c. Include as many sensory images as possible in the experience. d. Suggest that an image involving water may be more restful. Bottom of Form Top of Form What instruction should the nurse provide next? a. Apply gentle pressure over the opposing muscle. b. Apply firm pressure over the muscle. c. Relax the muscle completely. d. Tense the muscle fully. Bottom of Form Top of Form The nurse determines what time is best to educate the client about use of the PCA? a. The day before the surgery is scheduled. b. While she is in the post-anesthesia care unit c. When she is in pain and wants to learn how to obtain relief. d. After receiving a dose of medication from the PCA pump. Bottom of Form Top of Form What is the total dosage of morphine the client has received in the last 4 hours? a. 6 mg. b. 10 mg. c. 18 mg. d. 40 mg. Bottom of Form Top of Form What is the most likely reason for this change? A. She is receiving adequate pain control without the additional doses. B. She has developed tolerance to the effects of the medication. C. She is addicted to the dose of morphine that is still infusing. D. The IV line is infiltrated and she no longer obtains any pain relief. Bottom of Form Top of Form The nurse assesses the client\'s pain and determines that the evaluation of her use of the PCA pump is correct. The client\'s pain has lessened, and she no longer needs any demand doses of morphine. The nurse consults with the surgeon, and the morphine is discontinued. The client\'s new prescription for pain medication is hydrocodone/acetaminophen. What is the rationale for combining these two ingredients? A. The antagonistic effect of the two medications reduces the risk for adverse effects. B. The synergistic effect of the two medications improves pain control. C. The combination effect decreases the risk for significant allergic reactions. D. The equianalgesic effect allows each medication to work more efficiently. Top of Form What would be the best response by the nurse? a. \"You were receiving the docusate sodium because morphine is very constipating. You will no longer need to take it.\" b. \"Schedule III medications such as hydrocodone/acetaminophen tend to be more constipating than schedule II medications such as morphine.\" c. \"The stool softener should have been discontinued as soon as your bowel sounds returned after surgery.\" d. \"You may need to continue the docusate sodium because most opioid analgesics, including hydrocodone/acetaminophen, cause constipation.\" Bottom of Form Top of Form What is the priority intervention for the primary nurse of the client? a. Assess the client for signs of drug-seeking behavior. b. Ask the other nurses what behaviors they have observed. c. Remind the two nurses that it is inappropriate to discuss client information in the hallway where anyone can hear. d. Inform the other nurses that the client is not a drug addict. Top of Form The nurse\'s response demonstrates which ethical principle? a. Veracity. b. Fidelity. c. Teleology. d. Confidentiality.