Foundations Exam 1 Nclex Study Questions

Front 1

Which two factors contribute to the projected increase in the number of older adults?

1. Financial success and improved environment
2. Greater acceptance of older adults and medical problems
3. Improved medication plan and increase in Medicare funding
4. The aging of the baby boom generation and the growth of the population segment over age 85

Back 1

4. The aging of the baby boom generation and the growth of the population segment over age 85

Front 2

Which of the following is true about the theories of aging?

1. Genetic changes are solely responsible.
2. The client's environment is the main factor.
3. There is no single theory that explains aging.
4. The presence of disease causes a decline in function.

Back 2

3. There is no single theory that explains aging

Front 3

The three common conditions affecting cognition in older adults are:
1. Blindness, hearing loss, and stroke
2. Delirium, depression, and dementia
3. Cancer, Alzheimer's disease, stroke
4. Stroke, heart attack, and cancer of the brain

Back 3

2. delirium, depression, and dementia

Front 4

Sexuality is recognized as a factor in the care of older adults, thus:

1. The need to touch and be touched is decreased
2. A decrease in an older adult's libido does occur
3. Any expression of sexuality should be discouraged
4. All older adults, whether healthy or frail, need to express sexual feelings

Back 4

4. All older adults, whether healthy or frail, need to express sexual feelings

Front 5

Older adults experience a change in sexual activity. Which best explains this change?

1. The need to touch and be touched is decreased.
2. The sexual preferences of older adults are not as diverse.
3. Physical changes usually will not affect sexual functioning.
4. Frequency and opportunities for sexual activity may decline.

Back 5

4. Frequency and opportunities for sexual activity may decline.

Front 6

Visual acuity declines with age. Presbyopia is a progressive decline in:

1. Ability to see in darkness
2. Adaptation to abrupt changes from dark areas to light areas
3. The ability of the eyes to accommodate for close, detailed work
4. Distinguishing between blues and greens and among pastel shades

Back 6

3. The ability of the eyes to accommodate for close, detailed work

Front 7

A common age-related change in auditory acuity is called:

1. Presbyopia
2. Presbycusis
3. Calcification
4. Hypertrophy

Back 7

2. Presbycusis

Front 8

Taste buds atrophy and lose sensitivity, and appetite may decrease. The older adult is less able to discern:

1. Spicy and bland foods
2. Salty, sour, and bitter tastes
3. Hot and cold food temperatures
4. Moist and dry food preparations

Back 8

2. salty, sour, and bitter tastes

Front 9

Kyphosis, a change in the musculoskeletal system, leads to:

1. Decreased bone density in the vertebrae and hips
2. Increased risk for pathological stress fractures in the hip and wrist
3. Changes in the configuration of the spine that affect the lungs and thorax
4. Calcification of the bony tissues of the long bones, such as in the legs and arm

Back 9

3. Changes in the configuration of the spine that affect the lungs and thorax

Front 10

During change-of-shift report the night nurse states, “Mr. Sierra told me that he has had a bad experience with surgery in the past. I did not get a chance to ask him about it. We had a number of clients requiring procedures last night. He seems a bit anxious this morning.” As the day shift nurse, going to visit Mr. Sierra to clarify what experience he has had with surgery is an example of which critical thinking attitude?

1. Integrity
2. Discipline
3. Confidence
4. Perseverance

Back 10

2. discipline

Front 11

When you enter Mr. Ryan's room, he tells you, “I am not happy with the way the client care technician did my bath. He just seemed to be in a hurry and did not wash my back like I asked.” You decide to go talk with the technician to learn his side of the story as well. This is an example of:

1. Fairness
2. Curiosity
3. Risk taking
4. Responsibility

Back 11

1. Fairness

Front 12

The surgical unit has initiated the use of a pain rating scale, which is to be used to assess clients' pain severity during their postoperative recovery. Susan, the registered nurse (RN) assigned to Ms. Wills, looks at the pain flow sheet to see Ms. Wills' pain scores over the last 24 hours. Use of the pain scale is an example of which intellectual standard?

1. Deep
2. Relevant
3. Consistent
4. Significant

Back 12

consistent

Front 13

4. During the day the nurse spends time instructing a client in how to self-administer insulin. After discussing the techniques and demonstrating an injection, the nurse has the client try it. After two attempts the client obviously does not understand how to prepare the correct dose. When the nurse returns to the medication room, he discusses the situation with the charge nurse, reviewing his approach with the client and asking for her suggestions on his technique. This is an example of:

1. Reflection

2. Risk taking

3. Problem solving

4. Client assessment

Back 13

problem solving

Front 14

A nurse uses an institution's procedure manual to confirm how to insert a Foley catheter. The level of critical thinking the nurse is using is:

1. Commitment
2. Scientific method
3. Basic critical thinking
4. Complex critical thinking

Back 14

Basic critical thinking

Front 15

A client had hip surgery 24 hours ago. The nurse refers to the written plan of care, noting that the client has a drainage device collecting wound drainage. The health care provider is to be notified when drainage in the device exceeds 100 mL for the day. When the nurse enters the room, the nurse looks at the device and carefully notes the amount of drainage currently in the device. This is an example of:

1. Planning
2. Evaluation
3. Intervention
4. Assessment

Back 15

Assessment

Front 16

The nurse asks a client how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description in his textbook of loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurse's review of the literature is:

1. Experience
2. Problem solving
3. Knowledge application
4. Clinical decision making

Back 16

3. knowledge application

Front 17

The purpose of assessment is to:

1. Make a diagnostic conclusion
2. Delegate nursing responsibility
3. Teach the client about his or her health
4. Establish a database concerning the client

Back 17

4. Establish a database concerning the client.

Front 18

Assessment data must be descriptive, concise, and complete. An assessment should NOT include:

1. Subjective data from the client
2. A detailed physical examination
3. The use of interpersonal and cognitive skills
4. Inferences or interpretative statements not supported with data

Back 18

4. Inferences or interpretative statements not supported with data

Front 19

A nurse assesses a client who comes to the pulmonary clinic. “Tell me what medications you are on for your breathing problem. I see from your last visit that Dr. Russell recommended routine exercise. Can you also tell me how successful you have been following his plan?” The nurse's assessment covers which of Gordon's functional health patterns?

1. Value-belief pattern
2. Cognitive-perceptual pattern
3. Coping–stress tolerance pattern
4. Health perception–health management pattern

Back 19

4. Health perception-health management pattern

Front 20

The nurse asks a client, “Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?” This series of questions would likely occur during which phase of a client interview?

1. Working
2. Orientation
3. Termination

Back 20

1. Working

Front 21

During data clustering a nurse:

1. Provides documentation of nursing care
2. Reviews data with other health care providers
3. Makes inferences about patterns of information
4. Organizes cues into patterns that lead to identifying nursing diagnoses

Back 21

4. Organizes cues into patterns that lead to identifying nursing diagnoses

Front 22

What type of interview techniques does the nurse use when asking the question, “Do you have pain or cramping?” (Choose all that apply.)

1. Active listening
2. Open-ended questioning
3. Closed-ended questioning
4. Problem-oriented questioning

Back 22

3. Closed-ended questioning

Front 23

What techniques encourage a client to tell his or her full story? (Choose all that apply.)

1. Active listening
2. Back channeling
3. Use of open-ended questions
4. Use of closed-ended questions

Back 23

1,2,3 active listening, back channeling (uh-uh, all right, go on), use of open-ended questions

Front 24

8. You gather the following assessment data, which of the following cues form a pattern? (Choose all that apply.)

1. Client is restless.
2. Fluid intake for 8 hours is 800 mL.
3. Client states feels short of breath.
4. Client has drainage from surgical wound.
5. Respirations are 24 per minute and irregular.
6. Client reports loss of appetite for over 2 weeks.

Back 24

1,3,5 client is restless, client states feels short of breath, respiratons are 24 per minute and irregular

Front 25

A Nursing Diagnosis is:
1. the diagnosis and treatment of human responses
2. The advancement of the development, testing, and refinement of a common nursing language.
3. A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes
4. The identification of a disease condition based on a specific evaluation of physical signs, symtpoms, the client's medical history, and the results of diagnostic tests

Back 25

3.A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes

Front 26

Lisa reviews data she has regarding Ms. Devine's pain symptoms. She compares the defining characteristics for acute pain with those for chronic pain. In the end she selects acute pain as the correct diagnosis. This is an example of Lisa avoiding an error in:

1. Data collection
2. Data clustering
3. Data interpretation
4. Making a diagnostic statement

Back 26

4. Making a diagnostic statement

Front 27

One of the purposes of the use of standard formal nursing diagnostic statements is to:

1. Evaluate nursing care
2. Gather information on client data
3. Help nurses to focus on the role of nursing in client care
4. Facilitate understanding of client problems among health care providers

Back 27

4. Facilitate understanding of client problems among health care providers

Front 28

The nursing diagnosis "readiness for enhanced communication" is an example of a(n):

1. Risk nursing diagnosis
2. Actual nursing diagnosis
3. Potential nursing diagnosis
4. Wellness nursing diagnosis

Back 28

4. Wellness nursing diagnosis

Front 29

The nursing diagnosis "hypothermia" is an example of a(n):

1. Risk nursing diagnosis
2. Actual nursing diagnosis
3. Potential nursing diagnosis
4. Wellness nursing diagnosis

Back 29

2. Actual nursing diagnosis

Front 30

The word "impaired" in the diagnosis "Impaired physical mobility" is an example of a:

1. Descriptor
2. Risk factor
3. Related factor
4. Nursing diagnosis

Back 30

1. descriptor

Front 31

In the examples listed below, which nurse is acting to avoid a data collection error?

1. The nurse asks a colleague to chart his or her assessment data.
2. The nurse considers conflicting cues in deciding the correct nursing diagnosis.
3. The nurse assessing the edema in a client's lower leg is unsure of its severity and asks a co-worker to check it with him or her.
4. After doing an assessment the nurse critically reviews his or her level of comfort and competence with interview and physical assessment skills.

Back 31

3. The nurse assessing the edema in a client's lower leg is unsure of its severity and asks a co-worker to check it with him or her.

Front 32

“Unhappy and worried about health” is not a scientifically based nursing diagnosis, and it can lead to error in:

1. Data collection
2. Data clustering
3. Medical diagnosis
4. Diagnostic statement

Back 32

4. Diagnostic statement

Front 33

Casey is reviewing a client's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as:

1. Identifying the clinical sign instead of an etiology
2. Identifying a diagnosis based on prejudicial judgment
3. Identifying the diagnostic study rather than a problem caused by the diagnostic study
4. Identifying the medical diagnosis instead of the client's response to the diagnosis

Back 33

4. Identifying the medical diagnosis instead of the client's response to the diagnosis

Front 34

10. Which of the following are defining characteristics for the nursing diagnosis impaired urinary elimination? (Choose all that apply.)

1. Nocturia
2. Frequency
3. Urine retention
4. Inadequate urinary output
5. Receiving intravenous fluids
6. Sensation of bladder fullness

Back 34

1,2,3

Front 35

Sheila is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment Sheila anticipates the need to monitor the client's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. Sheila will have to establish priorities of care in which of the following situations? (Choose all that apply.)

1. The family comes to visit the client.
2. The client expresses concern about pain control.
3. The client's vital signs change, showing a drop in blood pressure.
4. The charge nurse approaches Sheila and requests a report at end of shift.

Back 35

2. The client expresses concern about pain control.
3. The client's vital signs change, showing a drop in blood pressure.

Front 36

Sheila's client signals with her call light. Sheila enters the room and finds the drainage tube disconnected, the IV has 100 ml of fluid remaining, and the client has asked to be turned. Which of the following should Sheila perform first?

1. Reconnect the drainage tubing.
2. Inspect the condition of the IV dressing.
3. Improve client's comfort, and turn to her side.
4. Go to the medication room, and obtain the next IV fluid bag.

Back 36

1. Reconnect the drainage tubing.

Front 37

In her nursing care plan, Sheila enters expected outcomes for her client. Which of the following expected outcomes are written correctly? (Choose all that apply.)

1. Client will remain afebrile until discharge.
2. IV site will be without phlebitis by the third postoperative day.
3. Provide incentive spirometer for deep breathing every 2 hours.
4. Client will report pain and turn more freely by the first postoperative day.

Back 37

1. Client will remain afebrile until discharge.
2. IV site will be without phlebitis by the third postoperative day.

Front 38

Sheila set a time limit for her outcomes. The time frame serves to:

1. Indicate which outcome has priority
2. Indicate the time it takes to complete an intervention
3. Indicate how long Sheila is scheduled to care for the client
4. Indicate when the client is expected to respond in the desired manner

Back 38

4. Indicate when the client is expected to respond in the desired manner

Front 39

A client-centered goal is a specific and measurable behavior or response that reflects a:

1. Physician's goal for the specific client
2. Client's desire for specified health care interventions
3. Client's response when compared to another client with a like problem
4. Client's highest possible level of wellness and independence in function

Back 39

4. Client's highest possible level of wellness and independence in function

Front 40

The nurse writes an expected outcome statement in measurable terms. An example is:

1. Client will be pain free.
2. Client will have less pain.
3. Client will take pain medication every 4 hours.
4. Client will report pain acuity less than 4 on a scale of 0 to 10.

Back 40

4. Client will report pain acuity less than 4 on a scale of 0 to 10.

Front 41

Sheila's client is experiencing nausea and abdominal distention postoperatively. Sheila initiates the interventions listed below. Which of the interventions are examples of independent interventions? (Choose all that apply.)

1. Provide frequent mouth care.
2. Maintain IV infusion at 100 mL/hr.
3. Administer Compazine via rectal suppository.
4. Consult with dietitian on initial foods to offer client.
5. Control aversive odors or unpleasant visual stimulation that trigger nausea.

Back 41

1. Provide frequent mouth care.
5. Control aversive odors or unpleasant visual stimulation that trigger nausea.

Front 42

Collaborative interventions are therapies that require:

1. Nurse and client intervention
2. Physician and nurse intervention
3. Client and physician intervention
4. Multiple health care professionals

Back 42

4. Multiple health care professionals

Front 43

When does implementation begin as the fourth step of the nursing process?

1. During the assessment phase
2. Immediately, in some critical situations
3. After the care plan has been developed
4. After there is mutual goal setting between nurse and client

Back 43

3. After the care plan has been developed

Front 44

Mr. Switzer is a 34-year-old client who had a surgical repair of an abdominal hernia this morning. At 12 noon the nurse records Mr. Switzer's vital signs on the recovery room flow sheet. The recording of vital signs is an example of:

1. Psychomotor skill
2. Indirect care measure
3. Physical care technique
4. Anticipating complications

Back 44

2. indirect care measure

Front 45

Before beginning insertion of a client's indwelling urinary catheter, the nurse considers the steps to take to avoid the possibility of breaking sterile technique, which could cause a urinary tract infection. This is an example of what type of decision making?

1. Identifying areas of assistance
2. Reviewing possible consequences of a nursing action
3. Reassessing the clinical situation to revise the care plan
4. Determining the probability of all consequences of the catheterization

Back 45

Book says 1-identifying areas of assistance

I think 2-reviewing possible consequences of a nursing action

Front 46

Interdisciplinary care plans represent:

1. All nursing personnel having input in the care plan
2. Contributions of all disciplines caring for the client
3. The client's expressed wishes and advance directives
4. Physicians and nurses working together to develop a plan of care

Back 46

2. contributions of all disciplines caring for the client

Front 47

Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following?

1. Safety
2. Nurse staffing
3. Confidentiality
4. Adequate pain relief

Back 47

1. safety

Front 48

In which of the following examples is a nurse applying critical thinking attitudes when performing a dressing change?

1. Following the procedural guideline for a dressing change
2. Seeking necessary knowledge on the steps of the procedure
3. Showing confidence in knowing which dressing materials to use
4. Being sure that the dressing covers the entire wound completely.

Back 48

3. Showing confidence in knowing which dressing materials to use

Front 49

Which steps do you follow when you are asked to perform a procedure with which you are unfamiliar? (Choose all that apply.)

1. Seek necessary knowledge.
2. Reassess the client's condition.
3. Collect all equipment necessary.
4. Have an experienced nurse available to assist.
5. Consider all possible consequences of the procedure.

Back 49

1,3,4

Front 50

A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides a glass of water for the client. Which of the following is an evaluative measure used by the nurse?

1. Suctioning the airway
2. Sitting client up in bed
3. Auscultating lung sounds
4. Asking client to describe type of discomfort

Back 50

3. auscultating lung sounds

Front 51

A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides a glass of water for the client. Which of the following is an appropriate evaluative criterion used by the nurse? (Choose all that apply.)

1. Client drinks contents of water glass.
2. Client's lungs are clear to auscultation in bases.
3. Client reports abdominal pain on scale of 0 to 10.
4. Client's rate and depth of breathing are normal with head of bed elevated.

Back 51

2. Client's lungs are clear to auscultation in bases
4. Client's rate and depth of breathing are normal with head of bed elevated

Front 52

The evaluation process, which determines the effectiveness of nursing care, includes five elements, one being interpreting findings. Which of the following is an example of interpretation?

1. Evaluating the client's response to selected nursing interventions
2. Selecting an observable or measurable state or behavior that will reflect goal achievement
3. Reviewing the client's nursing diagnoses and establishing goals and outcome statements
4. Matching the results of evaluative measures with expected outcomes to determine client's status

Back 52

4. Matching the results of evaluative measures with expected outcomes to determine client's status

Front 53

A goal specifies the expected behavior or response that indicates:

1. The specific nursing action was completed
2. The validation of the nurse's physical assessment
3. The nurse has made the correct nursing diagnoses
4. Resolution of a nursing diagnosis or maintenance of a healthy state

Back 53

4. Resolution of a nursing diagnosis or maintenance of a healthy state

Front 54

A client is recovering from surgery for removal of an ovarian tumor. It is one day after her surgery. Because she has an abdominal incision and dressing, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis?

1. Client will remain afebrile to discharge.
2. Client's wound will remain free of infection by discharge.
3. Client will receive ordered antibiotic on time over next 3 days.
4. Client's abdominal incision will remain covered with a sterile dressing for 2 days.

Back 54

2. Client's wound will remain free of infection by discharge.

Front 55

Unmet and partially met goals require the nurse to do which of the following? (Choose all that apply.)

1. Redefine priorities
2. Continue intervention
3. Discontinue care plan
4. Gather assessment data on a different nursing diagnosis
5. Compare the client's response with that of another client

Back 55

1. Redefine priorities
2. Continue intervention

Front 56

Following a bilateral mastectomy, a 50-year-old client refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the client with her hair combed and makeup applied. Which of the following is the best response from the nurse?

1. “What's the special occasion?”
2. “You must be feeling better today.”
3. “This is the first time I have seen you look this good.”
4. “I see you have combed your hair and put on makeup.”

Back 56

4. "I see you have combed your hair and put on makeup."

Front 57

When developing an appropriate outcome for a 15-year-old girl, the nurse considers that a primary developmental task of adolescence is to:

1. Form a sense of identity
2. Create intimate relationships
3. Separate from parents and live independently
4. Achieve positive self-esteem through experimentation

Back 57

1. Form a sense of identity

Front 58

Several staff members complain about a client's constant questions, such as “Should I have a cup of coffee or a cup of tea?” and “Should I take a shower now or wait until later?” Which interpretation of the client's behavior will help the nurses provide optimal care?

1. Asking questions is attention-seeking behavior.
2. Inability to make decisions reflects a self-concept issue.
3. Dependence on staff needs to be stopped immediately.
4. Indecisiveness is aimed at testing how the staff reacts.

Back 58

2. Inability to make decisions reflects a self concept issue.

Front 59

A depressed client is crying and verbalizes feelings of low self-esteem and self-worth such as “I'm such a failure … I can't do anything right.” The best nursing response would be to:

1. Remain with the client until the client stops crying
2. Tell the client that is not true and that every person has a purpose in life
3. Review recent behaviors or accomplishments that demonstrate skill ability
4. Reassure the client you know how he is feeling and that things will get better

Back 59

3. Review recent behaviors or accomplishments that demonstrate skill ability

Front 60

When an individual internalizes the beliefs, behavior, and values of role models into a personal, unique expression of self, the nurse would document this as:

1. Inhibition
2. Substitution
3. Identification
4. Reinforcement-extinction

Back 60

3. identification

Front 61

When caring for an 87-year-old client, the nurse needs to understand which of the following most directly influences the client's self-concept:

1. Attitude and behaviors of relatives providing care
2. Caring behaviors of the nurse and health care team
3. Level of education, economic status, and living conditions
4. Adjustment to role change, loss of loved ones, and physical energy

Back 61

4. Adjustment to role change, loss of loved ones, and physical energy

Front 62

An appropriate nursing diagnosis for an individual who experiences confusion in the mental picture of his physical self is:

1. Acute confusion
2. Disturbed body image
3. Chronic low self-esteem
4. Situational low self-esteem

Back 62

2. Disturbed body image

Front 63

The nurse asks the client, “How do you feel about yourself?” The nurse is assessing the client's:

1. Identify
2. Self-esteem
3. Body image
4. Role performance

Back 63

2. self esteem

Front 64

The nurse can increase a client's self-awareness by which of the following? (Choose all that apply.)

1. Helping the client to define her problems clearly
2. Allowing the client to openly explore thoughts and feelings
3. Reframing the client's thoughts and feelings in a more positive way
4. Having the client identify her positive and negative coping mechanisms

Back 64

1,2,3,4 (ALL)

Front 65

The vital functions necessary for survival, which include heart rate, blood pressure, and respiration, are controlled by the:

1. Adrenal gland
2. Pituitary gland
3. Medulla oblongata
4. Reticular formation

Back 65

3. Medulla oblongata

Front 66

While assessing a person for effects of the general adaptation syndrome, the nurse should be aware that:

1. Heart rate increases in the resistance state
2. Blood volume increases in the exhaustion stage
3. Vital signs return to normal in the exhaustion stage
4. Blood glucose level increases during the alarm reaction stage

Back 66

4. blood glucose level increases during the alarm reaction stage

Front 67

A client avoids emotional conflict by refusing to consciously acknowledge anything that might cause intolerable emotional pain. The client is using the defense mechanism:

1. Denial
2. Conversion
3. Dissociation
4. Displacement

Back 67

1. Denial

Front 68

When doing an assessment of a young woman who was in an automobile accident 6 months before, the nurse learns that the woman has vivid images of the crash whenever she hears a loud, sudden noise. The nurse recognizes this as:

1. Acute anxiety
2. Social phobia
3. Posttraumatic stress disorder
4. Borderline personality disorder

Back 68

3. Posttraumatic stress disorder

Front 69

A man is adjusting to chronic illness; this is an example of:

1. A situational factor
2. A maturational factor
3. A sociocultural factor
4. A developmental factor

Back 69

1. situational factor

Front 70

A child who has been in a house fire comes to the emergency department with her parents. The child and parents are upset and tearful. During the nurse's first assessment for stress she should say:

1. “Tell me whom I can call to help you.”
2. “Tell me what bothers you the most about this experience.”
3. “I will contact someone who can help get you temporary housing.”
4. “I will sit with you until other family members can come help you get settled.”

Back 70

2. “Tell me what bothers you the most about this experience.”

Front 71

The nurse is evaluating the coping success of a client experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. The nurse realizes that the client is coping successfully when the client says:

1. “I am going to learn to drive a car so I can be more independent.”
2. “My sister says she feels better when she goes shopping, so I will go shopping.”
3. “I have always felt better when I go for a long walk. I will do that when I get home.”
4. “I am going to attend a support group to learn more about multiple sclerosis and what I will be able to do.”

Back 71

4. “I am going to attend a support group to learn more about multiple sclerosis and what I will be able to do.”

Front 72

A client newly diagnosed with type 2 diabetes exhibits denial when she says, “My blood sugar was just a little high. I don't have diabetes.” The nurse responds:

1. “Let's talk about something cheerful.”
2. “Do other members of your family have diabetes?”
3. “I can tell that you feel stressed to learn that you have diabetes.”
4. With silence; the nurse understands the denial is a defense mechanism that assists in coping with a shock.

Back 72

4. With silence; the nurse understands the denial is a defense mechanism that assists in coping with a shock.

Front 73

A staff nurse is talking with her nursing supervisor about the stress she feels on the job. The supervising nurse recognizes that:

1. Nurses who feel stress usually pass the stress along to their clients
2. A nurse who feels stress is ineffective as a nurse and should not be working
3. Nurses who talk about feeling stress are unprofessional and should calm down
4. Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring

Back 73

4. Nurses frequently experience stress with the rapid changes in health care technology and organizational restructuring

Front 74

Generally a person's crisis is resolved in some way within approximately:

1. 2 weeks
2. 6 weeks
3. 1 month
4. 6 months

Back 74

6 weeks

Front 75

The nurse is having difficulty reading a physician's order for a medication. The nurse knows the physician is very busy and does not like to be called. The nurse should

1. Call a pharmacist to interpret the order
2. Call the physician to have the order clarified
3. Consult the unit manager to help interpret the order
4. Ask the unit secretary to interpret the physician's handwriting

Back 75

2. Call the physician to have the order clarified

Front 76

The client has an order for 2 tablespoons of Milk of Magnesia. The nurse converts this dose to the metric system and gives the client:

1. 2 mL
2. 5 mL
3. 16 mL
4. 30 mL

Back 76

4. 30 mL

Front 77

Most medication errors occur when the nurse:

1. Is caring for too many clients
2. Fails to follow routine procedures
3. Is administering unfamiliar medications
4. Is responsible for administering numerous medications

Back 77

2. Fails to follow routine procedures

Front 78

A client is to receive cephalexin (Keflex) 500 mg PO. The pharmacy has sent 250-mg tablets. The nurse gives:

1. ½ tablet
2. 1 tablet
3. 1½ tablets
4. 2 tablets

Back 78

4. 2 tablets

Front 79

When identifying a new client before administering medications, the nurse asks the client to state his name. The client does not state the correct name. The nurse asks again, and the client states still another name. What is the nurse's next action?

1. Laugh at the client, and tell him to quit “kidding.”
2. Give the medications without any further questioning.
3. Look at the client's armband to identify the client, and disregard what the client said.
4. Investigate the client's mental status before administering any further medications

Back 79

3. Look at the client's armband to identify the client, and disregard what the client said.

Front 80

A client is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority, in relation to safe medication administration, for the discharge nurse?

1. Set up the follow-up appointments with the physician for the client.
2. Ensure that someone will provide housekeeping for the client at home.
3. Ensure the home care agency is aware of medication and health teaching needs.
4. Make sure that the client has plenty of diapers and blue pads to take home with him.

Back 80

3. Ensure the home care agency is aware of medication and health teaching needs.

Front 81

A nursing student takes a client's antibiotic to his room. The client asks the nursing student what it is and why he should take it. The nursing student's reply includes the following information:

1. Only the client's physician can give this information
2. The name of the medication and a description of its desired effect
3. Information about medications is confidential and cannot be shared
4. Due to limits placed on nursing students, the client will have to speak with his assigned nurse about this

Back 81

2. The name of the medication and a description of its desired effect

Front 82

The nurse is administering a sustained-release capsule to a new client. The client insists that he cannot swallow pills. The best course of action for the nurse is to:

1. Ask the physician to change the order
2. Crush the pill with a mortar and pestle
3. Hide the capsule in a piece of solid food
4. Open the capsule and sprinkle it over pudding

Back 82

1. Ask the physician to change the order

Front 83

The nurse takes a medication to a client, and the client tells the nurse to take it away because she is not going to take it. The nurse's first action should be to:

1. Ask the client's reason for refusal
2. Explain that she must take the medication
3. Take the medication away and chart the client's refusal
4. Tell the client that her physician knows what is best for her

Back 83

1. Ask the client's reason for refusal

Front 84

The nurse selects the route for administering medication according to:

1. Hospital policy
2. The prescriber's orders
3. The type of medication ordered
4. The client's size and muscle mass

Back 84

2. The prescriber's orders

Front 85

A client is receiving an IV push medication. If this type of drug infiltrates into the outer tissues, the nurse will:

1. Continue to let the IV run
2. Apply a warm compress to infiltrated site
3. Follow facility policy or drug manufacturer's directions
4. Not worry about this because vesicant filtration is not a problem

Back 85

3. Follow facility policy or drug manufacturer's directions

Front 86

If a client who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects:

1. Sepsis
2. Phlebitis
3. Infiltration
4. Fluid overload

Back 86

2. phlebitis