A nurse is providing a back rub to a client just after administering a pain medication, with the hope that these two actions will help decrease the client’s pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation ANSWER Correct Answer: 3 Rationale 1: Assessment […]
The nurse is admitting a critically ill client to the intensive care unit. What question should the nurse ask regarding this client’s sleep history? 1. No questions should be asked. 2. “When do you usually go to sleep?” 3. “Do you have any problems with sleeping?” 4. “What are your bedtime rituals?” ANSWER Correct […]
The advantages of team nursing include: (Select all that apply) 1. Fosters team cooperation 2. Allows for ancillary staff autonomy 3. Strengthens the RN-client relationship 4. Facilitates decision making at the clinical level 5. Encourages collaboration between team members 6. Provides management experience for team leaders ANSWER ANS: 1, 4, 5, 6 An advantage […]
The nurse needs to collect a specimen from a client; however, the nurse has never collected this type of specimen in the past. What should the nurse do? 1. Notify the physician. 2. Ask another nurse to collect the specimen. 3. Consult the nursing procedure manual. 4. Delegate the collection of the specimen to unlicensed […]
The nurse is deciding on the type of dressing to use for a client. Which step of the deci-sion-making process is being used when the nurse observes the absorbency of different dressing brands? 1. Defining the problem 2. Making final decisions 3. Testing possible options 4. Considering consequences ANSWER ANS: 3 The nurse who […]
An experienced pediatric nurse is reassigned to an adult oncology floor because of staffing issues and immediately recognizes a lack of experience in this specialty. Which of the following nursing actions shows a lack of professionalism? 1. Politely declining the assignment 2. Filling out a report noting her dissatisfaction 3. Asking to work with another […]
The client has just learned that his motorcycle accident has resulted in his left leg being ampu-tated. When helping this client form goals and strategies for realistic goals, the nurse needs to assess the client’s: 1. Ideal and perceived self-concept 2. Intellectual and spiritual strengths 3. Involvement with significant others 4. Interests and past accomplishments […]
The home health nurse has scheduled a visit to a client who lives in a neighborhood that is known to be unsafe because of gang activity. Before going to the client’s home, the nurse should: 1. Call for an escort. 2. Call the client to let them know the nurse is on the way. 3. […]
The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse informs the parents that the child will be able to: 1. Say Da-da 2. Smile responsively 3. Differentiate strangers 4. Play social peekaboo games ANSWER ANS: 2 Two- and 3-month-old infants begin to smile responsively rather than reflexively. By […]
A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? 1. Inspect the abdomen. 2. Auscultate the abdomen. 3. Palpate the abdomen. 4. Assess vital signs. 5. Assess peripheral pulses. ANSWER Correct Answer: 1, 2, 3, 4 Rationale 1: The nurse should inspect the client’s abdomen. Rationale 2: […]
