Download NEW NURSING 706-HEALTH CARE INFORMATICS Q&A 2022 UPDATE and more Exams Nursing in PDF only on Docsity!
2022 UPDATE
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for the tracheostomy care. B. Obtaining cotton balls for the tracheostomy care. C. Obtaining sterile gloves for the tracheostomy care. D. Obtaining a sterile brush for the tracheostomy care. -Correct Answer= B) Obtaining cotton balls for the tracheostomy A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A. Place the client supine. B. Keep both side rails up. C. Raise the level of the bed. D. Inspect the client's mouth using a finger sweep. -Correct Answer= C) Raise the level of the bed A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? A. The client fully understands the provider's explanation of the procedure. B. The client has been informed about the risks and benefits of the procedure.
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C. The nurse witnessed the provider's explanation of the procedure. D. The signature on the preoperative consent form is the client's. -Correct Answer= D) The signature on the pre-operative consent form is the clients
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having nightmares about my upcoming surgery
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A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? A. Identify goals for client care. B. Obtain client information. C. Document nursing care needs. D. Evaluate the effectiveness of nurse care. -Correct Answer= B) Obtain client information A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side rails. B. Perform range-of-motion exercises to the wrists every 3 hrs. C. Remove the restraints one at a time. D. Obtain a PRN prescription for the restraints. -Correct Answer= C) Remove the restraints one at a time A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39. (102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority.
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C. temperature D. overdue menses -Correct Answer= C) Temperature A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carefully remove the gloves and follow with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection. -Correct Answer= C) Carefully remove the gloves and follow with hand hygiene A nurse is caring for a client who is postoperative and has parlytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus. B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea. D. Normal bowel sounds with increased peristalsis. -Correct Answer= B) Absent Val sounds with distention
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A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
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C) Sit and hold the clients hand
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A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. B. Grasp a skinfold on chest under clavicle, release, and note whether is springs back. C. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. D. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers. -Correct Answer= B) Grasp a skinfold on chest under clavicle, release, and note whether it's springs back. A nurse is caring for a client who has terminal illness. The client asks several questions about the nurse's religion beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness to the nurse. B. Encourage the client to express his thoughts about death and dying. C. Tell the client that religious beliefs are a personal matter. D. Offer to contact the client's minister or the facility's chaplain. -Correct Answer= B) Encourage the client to express his thoughts about death and dying A nurse is caring for a client who is unstable and has vital signs
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The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only blood pressure readings needed for the 15-min intervals. C. Obtain manual and automatic readings and compare them/. D. Disconnect the machine, and measure the blood pressure manually every 15 min. -Correct Answer= D) Disconnect the machine, and measure the blood pressure manually every 15 min A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45degree angle to the bed. D. Assume a narrow stance with feet 15 cm (6in) apart. -Correct Answer= C) Place a wheelchair at 45° angle to the bed Place in order: Inspection Palpation Percussion Auscultation -Correct Answer= Inspection, Auscultation, Palpation, Percussion A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room, when the client states she no longer wants to have the surgery.
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Which of the following actions should the nurse take?
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donate autologous blood before the surgery
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A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol- based hand rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands I will dry them from the elbows down." - Correct Answer= A) There are times I should use soap and water rather than an alcohol- based hand rub to clean my hands A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope. B. Check the client's pedal pulses. C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. D. Take the pulse at each peripheral site and count the rate for 30 seconds. -Correct Answer= C) Count the apical pulse rate for one full minute and describe the written in the chart A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm."
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D. "Using a cuff that is too small will result in an inaccurately high reading." -Correct Answer= D) Using a cuff that is too small will result in an inaccurately high rating A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercise. B. The client reports severe pain. C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery. -Correct Answer= B) The client reports severe A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching. A. "Drink a min. of 1,000 mL of fluid daily." B. "Increase your intake of refined-fiber foods" C. "Sit on the toilet 30 min after eating a meal. D. "Take a laxative every day to maintain regularity." -Correct Answer= C) Sit on the toilet 30 minutes after eating a meal A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection.
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Which of the following routes should the nurse use to obtain the temperature? A. Rectal B. Tympanic C. Oral
