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21 Cards in this Set

  • Front
  • Back

A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete?






During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?

A. Provide additional coffee on the client's breakfast tray

B. Exchange the client's grape juice for cranberry juice

C. Bring the client additional fruit at mid-morning

D. Encourage additional oral intake of juices & water

D. Encourage additional oral intake of juices and water

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician?

A. Clubbing of the fingers

B. Increased anterior-posterior diameter of the chest

C. Hemoptysis

D. Tachypnea

C. Hemoptysis

Identify a sociocultural factor that can lead to developmental problems.

A. Family relocation

B. Childhood obesity

C. Prolonged Poverty

D. Loss of stamina

C. Prolonged poverty

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to intervene?

A. The new nurse uses a black pen to chart

B. Thew new nurse charts consecutively on every other line

C. The new nurse ends each entry with signature and title

D. The new nurse keeps the password secure.

B. Thew new nurse charts consecutively on every other line

Patients who are unable to digest or absorb enteral nutrition benefit from parenteral nutrition. However, the goal to move toward use of the GI tract is constant because PN

A. Can only be given in the hospital setting

B. Cannot be used in pts in highly stressed situations

C. Can be given only by way of peripheral IV line

D. Can lead to villous atrophy and cell shrinkage

D. Can lead to villous atrophy and cell shrinkage

A nurse caring for a patient with COPD knows that which oxygen delivery device is most approprate

A. Nasal cannula

B. Simple face mask

C. Partial non-rebreather mask

D. Non rebreather mask

A. Nasal cannula

A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic?

"Your body isn't receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult."

A cardiac client develops increasing pedal edema. What diet modification is most important to give to this client?

Limit salt and fluid intake

A post-op pt has been placed on a clear liquid diet. The nurse should provide the pt with which item(s) that are allowed to be consumed on this diet?

Broth; Coffee; Gelatin; Pudding; Vegetable Juice; Pureed Vegetables




An expected outcome for an elderly patient with acute respiratory failure due to baterial pneumonia

Ability to perform ADLs without dyspnea

The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related changed?

Decreased lung defense mechanisms may cause ineffective airway clearance

The nurse is caring for a patient who will be receiving PN. To reduce the risk of developing sepsis, the nurse

Wears a sterile mask when changing the CVC dressing.

CVC - Central venous catheter. It goes straight to blood stream.

CVC puts PT at risk of infection because it goes very close to the heart; an infection here = big problems

Patient is transported to the ED after a serious motor vehicle accident. Pt complains of pain in his right chest where he struck the steering wheel. What is the primary client goal at this time?

Maintain adequate oxygenation

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3-4 times a week and take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?

Be sure to have a complete physical examination before beginning your planned exercise program

The nurse is assessing a patient with a right pneumothorax. Which finding would the nurse expect?

Absence of breath sounds on the right side

The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included?

Cleansing in a direction from the least contaminated area

The nurse is instructing a pt with HTN on the importance of choosing foods low in sodium. The nurse should teach the pt to limit the intake of which foods?

Smoked sausage

The pt is having at least 75% of his nutritional needs met by enteral feeding, so the physician has ordered the PN to be discontinued. However the nurse notices that the PN infusion has fallen behind. The nurse should

Taper the PN infusion gradually

A nurse wants to integrate all pertinent patient information into one record, regardless of the number of times a pt enters the health care system. Which term should the nurse use to describe this system?

Electronic Health Record

An elderly male client who is unresponsive following a cerebral vascular accident is receiving bolus enteral feedings through a gastrotomy tube. What is the best client position for administration of the bolus tube feedings?