ATI PRACTICE

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

. A. Although extinguishing the fire is part of the protocol for responding to a fire, it is not the priority action. B. Although activating the fire alarm is part of the protocol for responding to a fire, it is not the priority action. C. CORRECT: The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. The nurse should protect and move clients in close proximity to the fire. D. Although containing the fire by closing doors and windows is part of the protocol for responding to a fire, it is not the priority action.

. A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers

. A. CORRECT: Restorative health care involves intermediate follow‑up care for restoring health and promoting self‑care. Home health care is a type of restorative health care. B. CORRECT: Restorative health care involves intermediate follow‑up care for restoring health and promoting self‑care. Rehabilitation facilities are a type of restorative health care. C. Secondary health care includes the diagnosis and treatment of acute injury or illness. Diagnostic centers are a type of secondary health care. D. CORRECT: Restorative health care involves intermediate follow‑up care for restoring health and promoting self‑care. Skilled nursing facilities are a type of restorative health care. E. Tertiary health care is specialized and highly technical care. An oncology center is a type of tertiary health care

5. A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care

. A. CORRECT: Tertiary health care involves the provision of specialized and highly technical care, such as the care nurses deliver in intensive care units. B. CORRECT: Tertiary health care involves the provision of specialized and highly technical care, such as the care nurses deliver in oncology treatment centers. C. CORRECT: Tertiary health care involves the provision of specialized and highly technical care, such as the care nurses deliver in burn centers. D. This is an example of restorative care and also of tertiary prevention, but not of tertiary care.

A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

. A. Fidelity is the fulfillment of promises. Because donor organs are a scarce resource compared with the numbers of potential recipients who need them, no one can promise anyone an organ. Thus, this principle does not apply. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved with the qualifications for organ recipients. C. CORRECT: Justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources. D. Nonmaleficence is a commitment to do no harm. In this situation, harm can occur to organ donors and to recipients. The requirements of the organ procurement organizations are standard procedures and do not address avoidance of harm or injury.

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro‑organisms into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change.

. A. It would be difficult for the nurse to maintain a sterile field away from the bedside. But more important, this might not have any effect on the transmission of some micro‑organisms. B. The client might be unable to refrain from coughing and sneezing during the dressing change. C. CORRECT: Placing a mask on the client prevents contamination of the surgical wound during the dressing change. D. Keeping tissues close by for the client to use still allows contamination of the surgical wound.

A nurse at a provider's office is talking about routine screenings with a 45‑year‑old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. "So I don't need the colon cancer procedure for another 2 or 3 years." B. "For now, I should continue to have a mammogram each year." C."Because the doctor just did a Pap smear, I'll come back next year for another one." D."I had my blood glucose test last year, so I won't need it again till next year."

. A. The female client who has no specific family or personal history of colorectal cancer should begin screening procedures at age 50. B. CORRECT: The female client who is between the ages of 40 and 50 should have a mammogram annually. C. The female client who is between the ages of 30 and 65, with no family or personal history of cervical cancer, should have a Pap smear and human papilloma virus test every 5 years. D. The client who is age 45 should have a blood glucose test at least every 3 years. Unless there is a specific family or personal history of diabetes mellitus, annual blood glucose determinations are not necessary.

A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

. The nurse should remind family members who smoke to do so outside. B. CORRECT: The nurse should remind the client not to use nail polish or other flammable materials in the home. C. CORRECT: The nurse should have the client place a "No Smoking" sign near the front door, and possibly on the client's bedroom door. D. The nurse should tell the client to choose cotton materials for clothing and bedding. Woolen and synthetic materials create static electricity and could cause a fire. E. CORRECT: The nurse should remind all individuals to have a fire extinguisher at home. This is especially important for a client who is receiving oxygen.

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical‑surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form

A Delivering client care while showing signs of a substance use disorder is a legal issue, not an ethical dilemma. B. A nurse who threatens to restrain a client has committed assault. This is a legal issue, not an ethical dilemma. C. CORRECT: Making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client. D. The selection of a person to make health care decisions on a client's behalf is a legal decision, not an ethical dilemma.

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

A. A bottle of sterile solution is sterile on the inside and nonsterile on the outside. The nurse must prepare the sterile container of solution on the field before putting on sterile gloves. B. The 1‑inch border at the outer edge of the sterile field is not sterile. The nurse may not touch it with sterile gloves. C. CORRECT: The inner wrappings of any objects the nurse dropped onto the sterile field are sterile. The nurse may touch them with sterile gloves. D. CORRECT: Any objects the nurse dropped onto the sterile field during the setup are sterile. The nurse may touch the syringe with sterile gloves. E. CORRECT: One sterile gloved hand may touch the other sterile gloved hand because both are sterile.

A nurse is talking with a client who recently attended a cholesterol screening event and a heart‑healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention? A. Cholesterol screening B. Nutrition presentation C. Medication therapy D. Cardiac rehabilitation

A. A cholesterol screening is an example of secondary prevention. B. CORRECT: Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness. C. Starting medication therapy to lower cholesterol is an example of secondary prevention. D. Starting cardiac rehabilitation is an example of tertiary prevention

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions.

A. A nurse should place a client in a private room and initiate droplet precautions if he has pertussis. Negative‑pressure airflow is required for a client who is on airborne precautions. B. CORRECT: The nurse should wear a mask when within 3 ft of the client. C. CORRECT: The nurse should place a surgical mask on the client during transport to another area of the facility. D. The nurse should wear a gown and non‑sterile gloves when performing care that might result in contamination from body fluids. E. CORRECT: A gown should be worn if the nurse's clothing or skin might be contaminated with body secretions or excretions.

A nurse is caring for a client who presents with linear clusters of fluid‑containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster

A. A pink body rash is a manifestation of an allergic reaction. B. Red circles with white centers is a manifestation of ringworm. C. A red edematous rash bilaterally on the cheeks is a manifestation of systemic lupus erythematosus. D. CORRECT: Vesicles that follow along a unilateral dermatome is a manifestation of herpes zoster.

A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech‑language pathologist

A. A social worker can coordinate community services to help the client, but not specifically with dysphagia. B. A certified nursing assistant can help the client with feeding, but cannot assess and treat dysphagia. C. An occupational therapist can assist clients who have motor challenges to improve abilities with self‑care and work, but cannot assess and treat dysphagia. D. CORRECT: A speech‑language pathologist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties

A goal for a client who has difficulty with self‑feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist

A. A social worker can coordinate community services to help the client, but not specifically with self‑feeding devices. B. A certified nursing assistant can help the client with feeding, but does not typically procure adaptive devices for the client. C. A registered dietitian can help with educating the client about meeting nutritional needs, but cannot help with the client's physical limitations. D. CORRECT: An occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self‑care activities.

A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning. B. Select instructional materials appropriate for the older adult. C. Identify goals the nurse and the client agree are reasonable. D. Determine what the client knows about stress incontinence.

A. Active participation in the learning process is essential for the success of the session. However, this is not the priority action. B. It is essential for the nurse to prepare and select instructional materials appropriate for the client's age, developmental level, and other parameters. However, this is not the priority action. C. Establishing mutually agreeable goals is essential for the success of the session. However, this is not the priority action. D. CORRECT: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine how much the client knows about stress incontinence, the accuracy of this knowledge, and what the client needs to learn to manage this problem before instructing the client.

A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply.) A. Advance directives status B. Follow‑up care C. Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home health care agency

A. Advance directives status is important in transfer documentation, when other care providers will take over a client's care. They are not an essential component of a discharge summary for a client who is returning to his home. B. CORRECT: It is essential to include the names and contact information of providers and community resources the client will need after he returns home. C. CORRECT: The client will need written information detailing his medication and dietary therapy at home. A client who has had knee arthroscopy typically requires analgesics, possibly anticoagulants, and dietary instructions for avoiding postoperative complications such as constipation. D. Vital sign measurements are important in transfer documentation, when other care providers will take over a client's care. They are not an essential component of a discharge summary for a client who is returning home. E. CORRECT: It is essential to include the names and contact information of providers and community resources the client will need after returning home. For example, a client who had a knee arthroplasty might require physical therapy at home until he can travel to a physical therapy department or facility.

A nurse manager of a medical‑surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)

A. Although the charge nurse can provide all the care this client requires in the immediate postoperative period, administrative responsibilities might prevent the close monitoring and assessment this client needs. B. CORRECT: A client returning from surgery requires an RN's assessment and establishment of a plan of care, especially if the client is potentially unstable. C. Although PNs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time. D. Although APs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time, particularly assessment.

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is postoperative following an open reduction internal fixation of the ankle D. An older adult who is postoperative following a below‑the‑knee amputation

A. Although this client just had surgery, the client's age and type of surgery puts him at low risk for falls. B. Although this client requires telemetry, the client does not have as many risk factors as another client the nurse will admit. C. Although this client just had surgery, the client's age and type of surgery puts him at low risk for falls. D. CORRECT: The nurse should assign this client to a room near the nurses' station due to risk factors that include client's age plus the immobility and balance issues that result from this type of surgery. The client will also receive analgesics, which increase the risk for drowsiness, dizziness, and confusion.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer. C. Use a transfer belt and assist the client back into bed. D. Determine the client's ability to help with the transfer.

A. Although this might be a necessary assistive device for this client, obtaining a walker is not the priority action the nurse should take. B. Although this might be necessary for a safe transfer, calling for assistance is the not the priority action the nurse should take. C. Although this might be a necessary assistive device for the transfer of this client, using a transfer belt is not the priority action the nurse should take. D. CORRECT: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine the client's ability to help with transfers and then proceed with a safe transfer.

A nurse in a provider's office is collecting data from the mother of a 12‑month‑old infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the following domains? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic

A. An example of cognitive learning is stating the behavior the child will demonstrate when ready to toilet train. B. CORRECT: Affective learning has taken place because the client's ideas about toilet training changed. C. An example of psychomotor learning is performing the proper techniques for introducing the child to toilet training. D. Kinesthetic learning is a learning style, not a domain of learning.

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

A. As long as the provider has not reached over the sterile field, such as by placing the instrument on a near portion of the field, the field remains sterile. B. CORRECT: Fluid permeation of the sterile drape or barrier contaminates the field. C. CORRECT: Prolonged exposure to air contaminates a sterile field. D. CORRECT: Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field. E. The 1‑inch border at the outer edge of the sterile field is not sterile. Unless the client reached farther into the field, the field remains sterile.

A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality

A. Assault is an action that threatens harmful contact without the client's consent. The nurse has made no threats in this situation. B. CORRECT: The nurse gave the medication as a chemical restraint to keep the client from leaving the facility against medical advice. This is false imprisonment because the client neither requested nor consented to receiving the sedative. C. Negligence is a breach of duty that results in harm to the client. It is unlikely that the medication the nurse administered without his consent actually harmed the client. D. The nurse has not disclosed any protected health information, so there is no breach of confidentiality involved in this situation.

An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which of the following assignments should the PN question? A. Assisting a client who is 24‑hr postoperative to use an incentive spirometer B. Collecting a clean‑catch urine specimen from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered‑dose inhaler

A. Assisting a client to use an incentive spirometer is within the scope of practice of the PN. B. Collecting a clean‑catch urine specimen is within the scope of practice of the PN. C. Providing nasopharyngeal suctioning is within the scope of practice of the PN. D. CORRECT: The RN is responsible for primary teaching. The PN may only reinforce teaching.

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall‑risk assessment.

A. By restraining the client, the nurse risks liability for false imprisonment. B. Full side rails for this client puts the client at risk for a fall because he might attempt to climb over the rails to get out of bed. C. CORRECT: Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. CORRECT: Nonskid footwear keeps the client from slipping. E. CORRECT: A fall‑risk assessment serves as the basis for a plan of care the nurse can then individualize for the client

. A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

A. CORRECT: A fever indicates that the infection is affecting the whole body, and therefore systemic. B. CORRECT: Malaise indicates that the infection is affecting the whole body, and therefore systemic. C. Edema is a localized manifestation indicating a localized, not systemic, infection. D. Pain and tenderness is a localized manifestation indicating a localized, not systemic, infection. E. CORRECT: An increase in pulse and respiratory rate indicates that the infection is affecting the whole body, and therefore systemic

A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity

A. CORRECT: At the basic level, thinking is concrete and based on a set of rules, such as obtaining the prescription for diet progression. B. At the commitment level, the nurse expects to have to make choices without help from others and fully assumes the responsibility for those choices. However, postoperative protocols generally involve obtaining a prescription for diet progression. C. Advanced experience and knowledge at the complex level will prompt the nurse to request diet progression to full liquids based on active bowel sounds and the client's tolerance of clear liquid, not solely on the client's request. D. Integrity is a critical thinking attitude that comes into play when the nurse's opinion differs from that of the client. The nurse must then review her own position and decide how to proceed to help achieve outcomes satisfactory to all parties.

. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

A. CORRECT: By threatening the client, the AP is committing assault. Her threats could make the client become fearful and apprehensive. B. Battery is actual physical contact without the client's consent. Because the AP has only verbally threatened the client, battery has not occurred. C. Unless the AP restrains the client, there is no false imprisonment involved. D. Invasion of privacy involves disclosing infor

A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence

A. CORRECT: By using the electronic database, the nurse takes the initiative to increase his knowledge base, which is the first component of critical thinking. B. The nurse has had no prior experience with administering this medication to this client. C. Intuition requires experience, which the nurse lacks in administering this medication to this client. D. Competence involves making judgments, but no one can make a judgment about how the nurse handles researching and administering this medication to this client until he performs those tasks

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

A. CORRECT: Hypotension is a manifestation of heat stroke. B. Tachycardia is a manifestation of heat stroke. C. Hot, dry skin is a manifestation of heat stroke. D. Dyspnea is a manifestation of heat stroke

. A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. E. Tell the client about alternatives to having the surgery

A. CORRECT: It is the nurse's responsibility to verify that the surgeon obtained the client's consent and that he understands the information the surgeon gave him. B. CORRECT: It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that he is consenting voluntarily and appears to be competent to do so. The nurse also should verify that he understands the information the surgeon gave him. C. It is the surgeon's responsibility to explain the risks and benefits of the procedure. D. It is the surgeon's responsibility to describe the consequences of choosing not to have the surgery. E. It is the surgeon's responsibility to tell the client about any available alternatives to having the surgery.

A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical‑surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

A. CORRECT: It is within the scope of a CNA's duties to provide basic care to clients, such as bathing. B. CORRECT: It is within the scope of a CNA's duties to provide basic care to clients, such as assisting with ambulation. C. CORRECT: It is within the scope of a CNA's duties to provide basic care to clients, such as assisting with toileting. D. Determining pain level is a task that requires the assessment skills of licensed personnel, such as nurses. It is outside the scope of a CNA's duties. E. CORRECT: It is within the scope of a CNA's duties to provide basic care to clients, such as measuring and recording vital signs

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "He said he hurts after walking about 10 minutes." C. Pain rating is 3 on a scale of 0 to 10 D. Skin is pink, warm, and dry. E. The assistive personnel reports the client walked with a limp

A. CORRECT: Objective data includes information the nurse measures, such as vital signs. B. Subjective data includes a client's reported symptoms, even if told by a secondary source. C. Subjective data includes a client's reported symptoms. D. CORRECT: Objective data includes information the nurse observes, such as skin appearance. E. CORRECT: Objective data includes information on observations of others, such as family and staff. NCLEX® Connection: Health Promotion and

A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident‑prevention strategies should the nurse include? (Select all that apply.) A. Store toxic agents in locked cabinets. B. Keep toilet seats up. C. Turn pot handles toward the back of the stove. D. Place safety gates across stairways. E. Make sure balloons are fully inflated.

A. CORRECT: Parents must prevent toddlers from accessing dangerous substances. B. Easy access to the water in the toilet bowl could result in aspiration or drowning. C. CORRECT: Turn pot handles toward the back of the stove to prevent the toddler from reaching and pulling its contents down on themselves. D. CORRECT: Safety gates at the bottom of a staircase prevent toddlers from climbing stairs and falling backward. Safety gates placed at the top of a staircase prevent toddlers from falling down the stairs. E. Toddlers should not have access to balloons. Balloons can easily burst and toddlers can put fragments of the balloon or the entire deflated balloon in their mouth and asphyxiate.

. A nurse is cautioning the mother of an 8‑month‑old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? A. "My baby loved to play with his crib gym, but I took it away from him." B. "I just bought a soft mattress so my baby will sleep better." C."My baby really likes sleeping on the fluffy pillow we just got for him." D."I put the baby's car seat out of the way on the table after I put him in it."

A. CORRECT: Parents should remove gyms and mobiles at 4 to 5 months of age to prevent injury can occur from choking or strangulation. B. The nurse should remind the parents the infant's crib mattress should be firm and fit tightly to prevent suffocation. C. The nurse should remind the parents to remove pillows or stuffed animals from the crib to prevent possible suffocation. D. The nurse should remind the parents to place the infant seat on the ground level when not in a vehicle to prevent falls.

A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) A. Assembling puzzles B. Pulling wheeled toys C. Using musical toys D. Playing with puppets E. Coloring with crayons

A. CORRECT: Putting puzzles together helps a preschooler develop fine motor and cognitive skills. B. Pulling or pushing toys helps toddlers develop large muscles and coordination. C. CORRECT: Playing with musical toys helps a preschooler develop fine motor skills and coordination. D. CORRECT: Playing with puppets helps a preschooler develop oral language and actively use his imagination. E. CORRECT: Using crayons to color on paper or in coloring books helps a preschooler develop fine motor skills and coordination

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common‑source outbreaks

A. CORRECT: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies. B. CORRECT: Reporting of communicable and infectious diseases assists with determining public health policies. C. CORRECT: Reporting of communicable and infectious diseases assists with ensuring proper medical treatment is available. D. Endemic disease is already prevalent within a population, so reporting is not necessary. E. CORRECT: Reporting of communicable and infectious diseases assists with monitoring for common‑source outbreaks.

A nurse in a health clinic is caring for a 21‑year‑old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate‑specific antigen

A. CORRECT: Starting at age 20, the client should have examinations for testicular cancer, along with blood pressure and body mass index measurements and cholesterol determinations. B. Blood glucose testing begins at age 45. C. Testing for fecal occult blood usually begins at age 50. D. Testing for prostate‑specific antigen usually begins at age 50.

A nurse is admitting a client who has acute cholecystitis to a medical‑surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply.) A. Explain the roles of other care delivery staff. B. Begin discharge planning. C. Provide information about advance directives. D. Document the client's wishes about organ donation. E. Introduce the client to his roommate.

A. CORRECT: The client's hospitalization is likely to be more positive if the client understands who can perform which care activities. B. CORRECT: Unless the client is entering a long‑term care facility, discharge planning should begin on admission. C. CORRECT: The Patient Self‑Determination Act requires asking clients if they have advance directives and providing information about them. D. Asking about organ donation at the point of admission could instill fear unnecessarily. E. CORRECT: Any action that can reduce the stress of hospitalization is therapeutic. Introductions to other clients and staff can encourage communication and psychological comfort.

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall‑risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in his possession.

A. CORRECT: The first action the nurse should take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures. B. It is important for family members to be aware of the client's risk for falls. Providing instruction to the client and family is an appropriate nursing action, but this is not the priority action. C. It is important to eliminate safety hazards from the client's environment, but this is not the priority action. D. It is important for the client to use aids such as eyeglasses, he

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to his room. B. Conduct a client care conference. C. Review medical prescriptions. D. Develop a plan of care.

A. CORRECT: The greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient the client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside. B. The nurse should conduct a client care conference. However, another action is the priority. C. The nurse should review prescriptions in the medical record. However, another action is the priority. D. The nurse should develop a plan of care. However, another action is the priority.

. A nurse is talking with the parents of a 6‑month‑old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply.) A. Rolls from back to front B. Bears weight on legs C. Walks holding onto furniture D. Sits unsupported E. Sits down from a standing position

A. CORRECT: The infant should be able to roll from back to front by 6 months. B. CORRECT: The infant should be able to bear weight on legs by 7 months. C. The infant should be able to walk while holding furniture until around 11 months. D. CORRECT: The infant should be able to sit unsupported by 8 months. E. The infant should be able to sit down from a standing position until around 12 months

A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A. CORRECT: The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of his pain on a 0 to 10 scale. She also should have asked about the characteristics of his pain and assessed for any changes that might have contributed to worsening of the pain. B. The newly licensed nurse used the planning step of the nursing process when she decided that it was appropriate to administer the medication and, recognizing her level of experience in administering pain medication, prepared the dose under supervision from the unit staff. C. The newly licensed nurse used the implementation step of the nursing process when she administered the medication. D. The newly licensed nurse used the evaluation step of the nursing process when she checked the effectiveness of the pain medication in relieving the client's pain.

A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply.) A. Ensure that the client has possession of his valuables. B. Confirm that the rehabilitation center has a room available at the time of transfer. C. Assess how the client tolerates the transfer. D. Give a verbal transfer report via telephone. E. Complete a transfer form for the receiving facility.

A. CORRECT: The nurse should account for all of the client's valuable at the time of transfer. B. CORRECT: On the day of the transfer, the nurse should confirm that the receiving facility is expecting the client and that the room is available. C. It is the responsibility of the nurse at the receiving facility to assess the client upon arrival to determine how he tolerated the transfer. D. CORRECT: The nurse should provide the nurse at the receiving facility with a verbal transfer report in person or via telephone. E. CORRECT: The nurse should complete any documentation for the transfer, including a transfer form and the client's medical records.

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of her actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies.

A. CORRECT: The nurse should assist the client to recognize the benefits of her health‑promoting actions while also overcoming barriers to implementing actions. B. CORRECT: The nurse should collect information about who can help the client change unhealthful behaviors, and then suggest steps to have friends and family to become involved and supportive. C. CORRECT: The nurse should promote the client's use of any available community or online resources that can help the client progress toward meeting set goals. D. The nurse and the client should work together to devise and set mutually agreeable goals that are also realistic and achievable. E. CORRECT: The nurse should teach that stress is a contributing factor to cardiovascular disease, as well as many other specific and systemic disorders.

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique. B. The client is able to demonstrate the appropriate technique. C. The client states that he understands. D. The client is able to write the steps on a piece of paper.

A. Discussing the appropriate technique demonstrates learning, but it does not involve the use of motor skills. B. CORRECT: Demonstrating the appropriate technique indicates that psychomotor learning has taken place. C. Verbalizing understanding demonstrates learning, but it does not involve the use of motor skills. D. Writing steps on paper demonstrates learning, but it does not involve the motor skills essential for performing the procedure.

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain.

A. CORRECT: The nurse should collect further data on the client to determine why he has not achieved satisfactory pain relief, because various factors might be interfering with his comfort. The nursing process repeats in an ongoing manner across the span of client care. B. The nurse should not wait longer to see how the client would respond, but should to take action to determine why the client is not reaching achieving satisfactory pain relief. C. The nurse should not make random changes to the plan of care without gathering evidence to guide the nurse in knowing what new interventions can be necessary. D. The action by the nurse does not acknowledge the client's condition or that the current plan is ineffective.

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply). A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Complaint from a client's family member

A. CORRECT: The nurse should complete an incident report regarding a medication error. B. CORRECT: The nurse should complete an incident report regarding a needlestick. C. The nurse should report a conflict with a provider and nursing staff to the charge nurse or nurse manager., D. CORRECT: The nurse should complete an incident report following an omission of a prescription. E. The nurse should report concerns from a client's family member to the charge nurse or nurse manager

A nurse is assessing from a 2‑week‑old newborn during a routine checkup. Which of the following findings should the nurse expect? A. Sleeps 14 to 16 hr each day B. Posterior fontanel closed C. Pincer grasp present D. Hands remain in a closed position E. Current weight same as birth weight

A. CORRECT: The nurse should expect the newborn to sleep about 15 hr each day. B. The nurse should expect the posterior fontanel to close around 2 to 3 months of age. C. The nurse should expect the pincer grasp to develop around 8 months of age. D. CORRECT: The nurse should expect the newborn to keep hands in a closed position until about 2 months of life. E. CORRECT: The nurse should expect the newborn to have lost 5% to 10% of birth weight in the first few days of life, and to regain the weight by the second week of life.

3. A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training regarding surgical treatments for obesity D. Educating acute care nurses on postoperative comp

A. CORRECT: The nurse should identify obesity screenings at office visits as an example of primary health care. Primary health care emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings. B. The nurse should identify care that is provided in a rehabilitation center as an example of restorative health care. C. The nurse should identify specialized and highly technical care as an example of tertiary health care. D. The nurse should identify acute care of cl

. A nurse is caring for a group of clients on a medical‑surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) A. A client who has terminal cancer requests hospice care in her home. B. A client asks about community resources available for older adults. C. A client states that she wants her child baptized before surgery. D. A client requests an electric wheelchair for use after discharge. E. A client states that he does not understand how to use a nebulizer

A. CORRECT: The nurse should initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a client. B. CORRECT: The nurse should initiate a referral for a social worker to provide information and assistance in coordinating care for community resources available for clients. C. The nurse should initiate a referral for spiritual support staff if a client requests specific religious sacraments or prayers. D. CORRECT: The nurse should initiate a referral for a social worker to assist the client in obtaining medical equipment for use after discharge. E. The nurse should provide client teaching for concerns regarding the use of a nebulizer. If additional information is needed the nurse should initiate a referral for a respiratory therapist.

A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." B. "I will review the past medical history on the client's record to get more information." C."I will go carry out the new prescriptions from the provider." D."I will ask the client if his nausea has resolved."

A. CORRECT: The nurse should prioritize client problems during the planning step of the nursing process B. The nurse should review the client's history during the assessment/data collection step of the nursing process C. The nurse should implement nurse‑ and provider‑initiated actions during the intervention step of the nursing process. D. The nurse should gather information about whether the client's problems have been resolved during the evaluation step of the nursing process

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C."I will administer his medications." D."I will prepare to insert an airway."

A. During a seizure, the nurse should place the client in a side‑lying position to allow for drainage of secretions and to prevent his tongue from occluding the airway. B. CORRECT: During a seizure, the nurse should stay with the client and use the call light to summon assistance. C. The nurse should administer any medications the provider prescribes. D. The nurse should place nothing in the client's mouth except an oral airway, if he needs it. A tongue blade can cause injury and airway obstruction

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because it is not an emergency situation. E. Tell the charge nurse that the provider has prescribed morphine by telephone

A. CORRECT: The nurse should repeat the medication's name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation. B. CORRECT: Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication. C. CORRECT: The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr). D. Unrelieved pain can become an emergency situation without the appropriate pain management interventions. E. There is no need to inform the charge nurse every time a nurse receives a medication prescription, whether by telephone, verbally, or in the medical record.

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist

A. CORRECT: The provider must be knowledgeable about any medication he prescribes for the client, including its actions, effects, and interactions. B. It is not within the scope of a certified nursing assistant's duties to counsel a client about medications. C. CORRECT: A pharmacist must be knowledgeable about any medication she dispenses for the client, including its actions, effects, and interactions. D. CORRECT: A registered nurse must be knowledgeable about any medication she administers, including its actions, effects, and interactions. E. Although some analgesics can cause respiratory depression, requiring assistance from a respiratory therapist, it is not within this therapist's scope of practice to counsel the client about medications his provider prescribes.

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. C. Keep your knees slightly lower than your hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles.

A. CORRECT: To reduce the risk of injury, at least two staff members should reposition clients. B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the risk for injury. C. When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back. D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements helps prevent injury E. It is important to take a break every 15 to 20 min, not every 2 to 3 hr, from repetitive movements to flex and stretch joints and muscles.

A mother tells the nurse that her 2‑year‑old toddler has temper tantrums and says "no" every time the mother tries to help her get dressed. The nurse should recognize, the toddler is manifesting which of the following stages of development? A. Trying to increase her independence B. Developing a sense of trust C. Establishing a new identity D. Attempting to master a skill

A. CORRECT: Toddlers express a drive for independence by opposing the desires of those in authority and attempting to do everything themselves. B. Developing trust is a developmental task for infants. C. Establishing a new identity is the developmental task of an adolescent. D. Mastering a skill is a developmental task of school‑age children.

A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? A. Establish consistent boundaries for the toddler. B. Place the toddler in a room with the door closed. C. Inform the toddler how you feel when he misbehaves. . D. Use favorite snacks to reward the toddler

A. CORRECT: Toddlers need consistent boundaries for discipline to be effective. B. Placing a toddler in a room with the door closed can cause anxiety and fear. C. A toddler is unable to understand how another person is feeling. D. Using favorite foods as rewards can promote unhealthy eating habits.

A nurse uses a head‑to‑toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline

A. Confidence is feeling sure of one's own abilities. The nurse might feel confident of her physical assessment skills, but choosing a particular method or sequence requires another attitude. B. Perseverance is continuing to work at a problem until the nurse resolves it. This attitude does not apply here. C. Integrity is a practicing truthfully and ethically. This specific attitude does not apply here. D. CORRECT: Discipline is developing a systematic approach to thinking. Proceeding head to toe is a systematic approach to collecting the data a physical assessment yields.

A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document

A. Correction fluid implies that the nurse might have tried to hide the previous documentation or deface the medical record. B. CORRECT: The day and time confirm the recording of the correct sequence of events. C. CORRECT: Documentation must be factual, descriptive, and objective, without opinions or criticism. D. Too many abbreviations can make the entry difficult to understand. Nurses should minimize use of abbreviations, and use only those the facility approves. E. Documentation should be current. Waiting until the end of the shift can result in data omission.

A nurse is talking with the parent of a 4‑year‑old child who states that his child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? A. Offer the child a large snack before bedtime. B. Allow the child to watch an extra 30 min of TV in the evening. C. Have the child take an afternoon nap. D. Increase physical activity before bedtime

A. Eating a large snack, especially one that is heavy or has a high sugar content, is likely to provide stimulation that will make it more difficult for the child to fall asleep. This will not alleviate the child's nightmares. B. Watching TV is likely to provide stimulation that will make it more difficult for the child to fall asleep. This will not alleviate the child's nightmares. C. CORRECT: The nurse should encourage the parent to have the child take an afternoon nap and to empty her bladder before bedtime to alleviate nightmares and night terrors. D. Increasing physical activity is likely to provide stimulation that will make it more difficult for the child to fall asleep. This will not alleviate the child's nightmares.

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk taking D. Creativity

A. Fairness is using a nonjudgmental, objective approach in looking at clients and situations. This attitude does not apply here. B. CORRECT: The nurse is responsible for administering medications in a safe manner and according to standards of practice. Checking the medical record for allergies helps ensure safety. C. Risk taking is a calculated approach to solving a problem that is not responding to traditional methods. This attitude does not apply here. D. Creativity is an approach that uses imagination to find solutions to unique client problems. This problem is not unique, and it requires a straightforward solution.

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

A. Fidelity is the fulfillment of promises. The nurse has not made any promises; this is the client's decision. B. CORRECT: In this situation, the client is exercising his right to make his own personal decision about surgery, regardless of others' opinions of what is "best" for him. This is an example of autonomy. C. Justice is fairness in care delivery and in the use of resources. Because the client has chosen not to use them, this principle does not apply. D. Nonmaleficence is a commitment to do no harm. In this situation, harm can occur whether or not the client has surgery. However, because he chooses not to, this principle does not apply.

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

A. Fidelity is the fulfillment of promises. The nurse is not addressing a specific promise when she determines the appropriateness of a prescription for the client. Thus, this principle does not apply. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved when the nurse questions the client's prescription. C. Justice is fairness in care delivery and in the use of resources. In this situation, the nurse is delivering responsible client care and is not assessing available resources. This principle does not apply. D. CORRECT: Nonmaleficence is a commitment to do no harm. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

A. Fidelity is the fulfillment of promises. Unless the nurse has specifically promised the client a pain‑free recovery, which is unlikely, this principle does not apply to this action. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. In this situation, the nurse is delivering responsible client care. This principle does not apply. C. Justice is fairness in care delivery and in the use of resources. Pain management is available for all clients who are postoperative, so this principle does not apply. D. CORRECT: Beneficence is action that promotes good for others, without any self‑interest. By administering pain medication before the client attempts a potentially painful exercise like ambulation

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? A. "I will get the caller off the phone as soon as possible so I can alert the staff." B. "I will begin evacuating clients using the elevators." C."I will not ask any questions and just let the caller talk." D."I will listen for background noises."

A. In the event of a bomb threat, the nurse should keep the caller on the line in order to trace the call and to collect as much information as possible. B. The nurse should avoid using the elevators so that they are free for the authorities to use, and should not evacuate clients unless directed to by facility protocol. C. The nurse should ask the caller about the location of the bomb and the time it is set to explode in order to gather as much information as possible. D. CORRECT: In order to identify the location of the caller, the nurse should listen for background noises such as church bells, train whistles, or other distinguishing noises.

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. Supine B. Semi‑Fowler's C. Semi‑prone D. Trendelenburg

A. In the supine position, the client lies on his back with his head and shoulders elevated on a pillow. This angle will not prevent regurgitation. B. CORRECT: In the semi‑Fowler's position, the client lies supine with the head of the bed elevated 15° to 45° (typically 30°). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings. C. In the semi‑prone or Sims' position, the client is on his side halfway between lateral and prone positions. This position is not safe because it promotes regurgitation. D. In the Trendelenburg position, the entire bed is tilted with the head of the bed lower than the foot of the bed. This position is not safe because it promotes regurgitation.

As part of the admission process, a nurse at a long‑term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing

A. It is important to calculate body mass index to help determine appropriateness of the client's weight status and related risks. However, there is a higher priority. B. It is important for the nurse to know and try to follow the meal schedule the client follows at home. However, there is a higher priority. C. It is important for the nurse to know which foods are the client's favorites in case it becomes difficult to get the client to consume adequate nutrients. However, there is a higher priority. D. CORRECT: The greatest risk to this client related to a nutrition‑related evaluation is from difficulty swallowing, or dysphagia. It puts the client at risk for aspiration, which can be life‑threatening

. A nurse on a medical‑surgical unit has received change‑of‑shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer

A. It would be inappropriate to delegate the feeding of a client who has aspiration pneumonia to an AP because the client is at risk for further aspiration. B. Either an RN or an PN, not an AP, may reinforce teaching. C. CORRECT: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to an AP. D. Either an RN or an PN, not an AP, may apply a sterile dressing.

A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (Select all that apply.) A. Preferred provider organization (PPO) B. Medicare C. Long‑term care insurance D. Exclusive provider organization (EPO) E. Medicaid

A. PPOs are privately funded. B. CORRECT: Medicare is federally funded. C. Long‑term care insurance is privately funded. D. EPOs are privately funded. E. CORRECT: Medicaid is federally funded.

A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medications? (Select all that apply.) A. Reassure the child an injection will not hurt. B. Mix oral medications in a large glass of milk. C. Offer the child choices when possible. D. Have the parents bring in a favorite toy from home. E. Engage the child in pretend play with a toy medical kit.

A. Telling the preschooler the injection will not hurt will cause the child to distrust the nurse. B. Oral medications should be mixed in a small amount of fluid to increase the chance of the child taking the entire dosage. C. Offer the child choices when possible gives the child some control and helps reduce the child's fears. D. CORRECT: Having familiar and cherished objects nearby is therapeutic for children during their hospitalization and is useful as a distraction during uncomfortable procedures. E. CORRECT: Pretend play helps children determine the difference between reality and fantasy (imagined fears), especially with the assistance of the nurse during hospitalization.

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates with his slippers on over his antiembolic stockings. C. The client uses a front‑wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of his breakfast this morning.

A. The AP does not need to know the status of the client's roommate to complete this assignment. B. CORRECT: To complete this assignment safely, the AP should make sure the client wears stockings and slippers. C. CORRECT: To complete this assignment safely, the AP should make sure the client uses a front‑wheeled walker. D. CORRECT: To complete this assignment safely, the AP should know that the client should be feeling the effects of the pain medication. E. The AP does not need to know the client's allergy status to complete this assignment. F. The AP does not need to know the client's food intake to complete this assignment

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

A. The APs should apply alcohol rubs to dry hands, and wet the hands first before applying soap for handwashing. B. CORRECT: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes. C. The APs should use warm water to minimize the removal of protective skin oils. D. CORRECT: If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands. E. The APs should dry their hands with a clean paper towel. This helps prevent chapped skin.

A nurse is reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the parents of preschoolers. Which of the following vaccines should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type B B. Varicella C. Polio D. Hepatitis A E. Seasonal influenza

A. The CDC recommends Haemophilus influenzae type B immunizations during infancy, but not generally beyond 18 months of age. B. CORRECT: The CDC recommends a varicella (chickenpox) immunization during the preschool years. C. CORRECT: The CDC recommends a polio immunization during the preschool years. D. The CDC recommends hepatitis A immunizations during infancy, but not generally beyond 24 months of age. E. CORRECT: The CDC recommends seasonal influenza immunizations during the preschool years

A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply.) A. Building models B. Working with clay C. Filling and emptying containers D. Playing with blocks E. Looking at books

A. Toddlers are not cognitively or physically capable of building models. This play activity is acceptable for school‑age children. B. Toddlers put small objects into their mouths and can easily swallow bits of clay. This activity is unacceptable for a toddler. C. CORRECT: This activity can help a toddler develop fine motor skills and coordination. D. CORRECT: This activity can help a toddler develop fine motor skills. E. CORRECT: This activity can help a toddler prepare to learn to read

A nurse is discussing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse include? (Select all that apply.) A. A single electronic records password is provided for nurses on the same unit. B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of her medical record. E. A nurse may photocopy a client's medical record for transfer to another facility

A. The HIPAA Privacy Rule requires the protection of clients' electronic records. The rule states that electronic records must be password protected and each staff person should use an individual password to access information. B. CORRECT: The HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code. C. CORRECT: The HIPAA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot overhear it. A unit nurses' station is considered a private and secure location. D. CORRECT: The HIPAA Privacy Rule states that clients have a right to read and obtain a copy of their medical record. E. CORRECT: The HIPAA Privacy Rule states that nurses may only photocopy a client's medical record if it is to be used for transfer to another facility or provider

A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow. B. Lie flat on her stomach with her head to one side. C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table. D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her

A. The client is describing the supine position, not the orthopneic position. B. The client is describing the prone position, not the orthopneic position. C. CORRECT: The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD. D. The client is describing the lateral or side‑lying position, not the orthopneic position.

A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C."I plan to write that I don't want them to keep me on a breathing machine." D."I will get my regular doctor to approve my plan before I hand it in at the hospital."

A. The client may designate any competent adult to be his health care proxy. It does not have to be his spouse. B. The hospital staff must ask the client whether he has prepared advance directives and provide written information about them if he has not. The nurse should document whether the client has signed the advance directives. The hospital staff cannot refuse care based on the lack of advance directives. C. CORRECT: The client has the right to decide and specify which medical procedures he wants when a life‑threatening situation arises. D. The client does not need his provider's approval to submit his advance directives. However, he should give his primary care provider a copy of the document for his records.

. A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart‑healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions. B. Ask the client to explain how to select or prepare meals. C. Encourage the client to fill out an evaluation form. D. Ask the client if she has resources for further instruction on this topic.

A. The client stated that she understood the content, so she might not ask any questions that would help the nurse evaluate learning. B. CORRECT: A useful strategy for evaluating learning is to ask the client to explain in her own words how she will implement what she learned. C. An evaluation form usually gives the client a means of evaluating the teaching. It might not offer clues about what the client has learned. D. The nurse should identify the client's resources early in the instructional process. At this point, the exploration of resources does not help the nurse evaluate the client's learning.

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incision." B. "Will you give me pain medicine after the surgery?" C."Can you tell me about how long the surgery will take?" D."My roommate listens to everything I say."

A. The client's concern about her spouse seeing the incision could indicate anxiety or depression. B. The client's request for pain medicine could indicate fear and anxiety. C. CORRECT: Asking a concrete question about the surgery indicates that the client is ready to discuss the surgery. The client's new diagnosis of cancer can cause anxiety, fear, or depression, all of which can interfere with the learning process. D. The lack of privacy due to the presence of a roommate can be a barrier to learning.

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

A. The flap closest to the nurse's body is the innermost flap and the last one to unfold. B. The nurse should unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap the nurse should unfold first. C. The nurse should unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap the nurse should unfold first. D. CORRECT: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one farthest from her body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it.

A nurse is talking with a parent who is concerned about several issues with her preschooler. Which of the following issues should the nurse identify as the priority? A. "My son mimics my husband getting dressed." B. "My son has temper tantrums every time we tell him to do something he doesn't want to do." C."I think my son truly believes that his toys have personalities and talk to him." D."I feel bad when I see my son trying so hard to button his shirt."

A. The identification of the son with his father through imitation is nonurgent because it is an expected response for a preschooler. It is common for preschoolers to identify with the parent of the same sex and to mimic that parent's behavior. B. CORRECT: When using the urgent vs. nonurgent approach to client care, the priority issue is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage of development. According to Erikson, it is a task of the toddler stage to develop autonomy vs. shame and doubt. This preschooler is still acting out with negativism, which is a persistent negative response to requests, often manifested in tantrums. He is still struggling with this task and needs assistance in working through that stage. C. The strong imagination of a preschooler is nonurgent because it is expected for preschoolers to have an active imagination as well as an imaginary friend. It is common for preschoolers to manifest misperceptions in thinking, such as animism (the belief that inanimate objects are alive). D. Attempting to master activities such as dressing themselves is nonurgent because it is an expected activity for a preschooler. It is common for preschoolers, who are in the stage Erikson describes as initiative vs. guilt, to face the challenge of mastering activities they can perform independently, such as dressing themselves.

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) A. Writing a prescription for morphine sulfate as needed for pain. B. Inserting a nasogastric (NG) tube to relieve gastric distention. C. Showing a client how to use progressive muscle relaxation. D. Performing a daily bath after the evening meal. E. Repositioning a client every 2 hr to reduce pressure ulcer risk.

A. The nurse must have a prescription from the provider to administer a medication. After obtaining the prescription, the nurse has the flexibility to determine when to administer a PRN medication. B. The nurse must have a prescription from the provider for the insertion of an NG tube. This is a provider‑initiated intervention. C. CORRECT: Showing a client how to use progressive muscle relaxation is an appropriate nurse‑initiated intervention for stress relief. Unless it is a contraindication for a specific client, the nurse can use this technique with clients without a provider's prescription. D. CORRECT: Performing a bath is a routine nursing care procedure. Unless it is a contraindication for a specific client, the nurse can determine when bathing is optimal for a client without a provider's prescription. E. CORRECT: Repositioning a client every 2 hr is an appropriate nurse‑initiated intervention for clients. Unless it is a contraindication for a specific client, the nurse can use this strategy without a provider's prescription.

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.) A. Open doors to client rooms. B. Place blankets over clients who are confined to beds. C. Move beds away from the windows. D. Draw shades and close drapes. E. Instruct ambulatory clients in the hallways to return to their rooms.

A. The nurse should close all client doors to minimize the threat of flying glass and debris. B. CORRECT: The nurse should place blankets over clients to protect them from shattering glass or flying debris. C. CORRECT: The nurse should move all beds away from windows to protect clients from shattering glass or flying debris. D. CORRECT: The nurse should draw shades and close drapes to protect clients against shattering glass. E. The nurse should instruct ambulatory clients to go to the hallways, away from windows, or other secure location designated by the facility.

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4‑inch laceration to the head C. A client who has partial‑thickness and full‑thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia

A. The nurse should give the lowest priority to a client who is not expected to live. The nurse should provide comfort measures for this client (Expectant Category: Class IV). B. The nurse should give third priority to the client who has minor injury that is not life‑threatening, such as a laceration to the head (Nonurgent Category: Class III). C. CORRECT: The nurse should give first priority to the client who has the greatest chance of survival with prompt intervention. If not treated immediately, a client who has burns to his face, neck, and chest is at risk for airway obstruction, but is otherwise expected to live. Therefore, this client is the highest priority (Emergent Category: Class I). D. The nurse should give second priority to the client who has major fractures (Urgent Category: Class II).

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence‑based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining if medications are safe for administration to clients

A. The nurse should identify that utilization review committees have the responsibility of monitoring for appropriate diagnosis and treatment according to evidence‑based practice for diagnosis and treatment of hospitalized clients. B. CORRECT: The nurse should identify that state licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations. C. The nurse should identify that the Joint Commission has the responsibility of setting quality standards for accreditation of health care facilities. D. The nurse should identify that the U.S. Food and Drug Administration has the responsibility of determining if medications are safe for administration to clients.

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body.

A. The nurse should include that carbon monoxide cannot be seen, smelled, or tasted. B. The nurse should tell the client to inspect gas‑burning furnaces, water heaters, and appliances annually. C. The nurse should inform the client that carbon monoxide impairs the body's ability to use oxygen, but the lungs are not damaged. D. CORRECT: The nurse should warn the client that carbon monoxide is very dangerous because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products. D. Healthy individuals usually recover from the illness in a few weeks. E. Handling raw and fresh food separately can prevent food poisoning.

A. The nurse should include that most food poisoning is caused by bacteria such as Escherichia coli, Listeria monocytogenes, and Salmonella. B. CORRECT: The nurse should warn the client that very young, very old, immunocompromised, and pregnant individuals are at risk for complications from food poisoning. C. CORRECT: The nurse should include that clients who are at high risk should follow a low‑microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, and other dairy products. D. The nurse should inform the client that healthy individuals usually recover from the illness in a few days. E. CORRECT: The nurse should include interventions to prevent food poisoning, such as performing proper hand hygiene, cooking meat and fish to the correct temperature, handling raw and fresh food separately to avoid cross‑contamination, and refrigerating perishable items.

A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130° F." B. "Once my baby can sit up, he should be safe in the bathtub." C."I will place my baby on his stomach to sleep." D."Once my infant starts to push up, I will remove the mobile from over the crib."

A. The nurse should instruct the parent to set the home water heater temperature to 120° F or less. B. Although the baby can hold his head above the water by sitting up, this does not make the child safe in the bathtub. The nurse should warn the parent to never leave an infant or toddler alone in the bathtub. C. The nurse should remind the parent to place the infant on his back to sleep, and to remove suffocation hazards from the crib. D. CORRECT: The parent should plan to remove crib toys, such as mobiles, from over the bed as soon as the infant begins to push up so the infant is unable to touch them.

A nurse is reviewing car seat safety with the parents of a 1‑month‑old infant. When reviewing car seat use, which of the following instructions should the nurse include? A. Use a car seat that has a three‑point harness system. B. Position the car seat so that the infant is rear‑facing. C. Secure the car seat in the front passenger seat of the vehicle. D. Convert to a booster seat after 12 months.

A. The nurse should instruct the parents to provide a car seat with a five‑point harness system. B. CORRECT: The nurse should instruct the parents to position the infant car seat in a rear‑facing position in the center of the vehicle seat, when possible. C. The nurse should instruct the parent to place the infant car seat in the back seat to reduce the risk for injury in the event of a crash. D. The nurse should instruct the parents to continue using an infant seat until the child reaches age 2, or meets the height and weight limits for the seat.

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A. Alert the American Nurses Association. B. Fill out an incident report. C. Report the observations to the nurse manager on the unit. D. Leave the nurse alone to sleep

A. The nurse should not alert the American Nurses Association. The state's board of nursing regulates disciplinary action and can revoke a nurse's license for substance use. B. The nurse should not fill out an incident report. Incident reports are filed to document an accident or unusual occurrence. C. CORRECT: Any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager. D. The nurse should not leave the nurse alone to sleep. Although the nurse is not responsible for solving the problem, she does have a duty to take action since she has observed the problem.

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water. B. Wash the affected area with antibacterial soap. C. Brush the chemical off the skin and clothing. D. Leave the clothing in place until emergency personnel arrive.

A. The nurse should not apply water to a dry chemical exposure because it could activate the chemical and cause further harm. B. The nurse should wash the skin with antibacterial soap in the event of a biological exposure. C. CORRECT: The nurse should use a brush to remove the chemical off the skin and clothing. D. The nurse should plan to remove the client's clothing following appropriate decontamination.

A nurse is preparing information for change‑of‑shift report. Which of the following information should the nurse include in the report? A. Input and output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record

A. Unless there is a significant change in intake and output, the oncoming nurse can read that information in the chart. B. Unless there is a significant change in blood pressure measurements since the previous day, the oncoming nurse can read that information in the chart. C. CORRECT: The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit. D. Unless there is a significant change in the medication routine, the oncoming nurse can read that information in the chart.

A nurse on a medical‑surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm Hg E. A client who has acute appendicitis and is scheduled for an appendectomy

A. The nurse should recognize that a client who is receiving IV fluid and electrolytes requires ongoing nursing care and is therefore unstable for discharge. B. The nurse should recognize that a client who has a nasogastric tube requires ongoing nursing care and is therefore unstable for discharge. C. CORRECT: The nurse should identify a client who is scheduled elective surgery is stable and is therefore appropriate to recommend for discharge. D. CORRECT: A blood pressure 135/85 mm Hg is within the reference range for prehypertension. The nurse should identify this client as stable and appropriate to recommend for discharge. E. The nurse should recognize that a client who has an acute illness and is scheduled for surgery requires ongoing nursing care and is therefore unstable for discharge.

A nurse is caring for a 20‑year‑old client who is sexually active and has come to the college health clinic for a first‑time checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? A. Measure vital signs. B. Encourage HIV screening. C. Determine risk factors. D. Instruct the client to use condoms.

A. The nurse should take vital signs when determining the client's need for health promotion and disease prevention. However, there is another action the nurse should take first. B. The nurse may suggest for the client to have a HIV screening when determining health promotion and disease prevention. However, there is another action the nurse should take first. C. CORRECT: The first action the nurse should take using the nursing process is assessment. The nurse should talk with the client first to determine what risk factors the client might have before initiating the appropriate health promotion and disease prevention measures. D. The nurse may provide for the client the use of condoms to decrease sexual health risk when determining the client's need for health promotion and disease prevention. However, there is another action the nurse should take first.

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

A. The prodromal stage consists of nonspecific manifestations of the infection. B. The incubation period consists of the time when the pathogen first enters the body prior to the appearance of any manifestations of infection. C. During convalescence, manifestations of the infection fade. D. CORRECT: The illness stage is when the client experiences manifestations specific to the infection.

A nurse is preparing an in‑service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply.) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances

A. The right client is one of the rights of medication administration, not of delegation. B. CORRECT: The right supervision and evaluation is one of the five rights of delegation. They also include the right task and the right person. C. CORRECT: Right direction and communication is one of the five rights of delegation. They also include the right task and the right person. D. Although the delegatee needs to know whether there is a time frame or a specific time to perform the task, the right time is not one of the five rights of delegation. It is one of the rights of medication administration. E. CORRECT: The right circumstances is one of the five rights of delegation. They also include the right task and the right person.

The mother of a 7‑month‑old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? (Select all that apply.) A. "It might be good to add bananas, as they can help with loose stools." B. "Let's make a list of the foods he is eating so we can spot any problems." C."Did the changes begin after you started one particular food?" D."Has he been vomiting since he started these new foods?" E. "Most babies react with a little indigestion when you start new foods."

A. This response by the nurse suggests an intervention without first determining the cause of the infant's problem. B. CORRECT: This response by the nurse is an attempt to assess about the infant's diet to help determine whether a food allergy or intolerance is the cause of the diarrhea and fussiness. C. CORRECT: This response by the nurse is an attempt to assess the infant's diet to help determine which food triggered the infant's behavior change. Parents should introduce one food at a time to help identify allergies or intolerances. D. CORRECT: This response by the is an attempt to assess for other changes caused by the infant's diet which could be linked to a food allergy or intolerance, such as vomiting, rash, or constipation. E. This response by the nurse is nontherapeutic because it involves stereotyping, and offers false reassurance without any attempt to understand the infant's problem.

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C."To broaden my base of support, I should spread my feet apart." D."When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward."

A. To reduce the risk of falling, the line of gravity should fall within the base of support, not outside it. B. CORRECT: Being closer to the ground lowers the center of gravity, which leads to greater stability and balance. C. CORRECT: Spreading the feet apart increases and widens the base of support. D. CORRECT: Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevent injury and instability. E. To promote stability, the nurse should move the rear leg back when pulling on an object.

A nurse is reviewing nutritional guidelines with the parents of a 2‑year‑old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? A. "I should keep feeding my son whole milk until he is 3 years old." B. "It's okay for me to give my son a cup of apple juice with each meal." C."I'll give my son about 2 tablespoons of each food at mealtimes." D."My son loves popcorn, and I know it is better for him than sweets."

A. When toddlers turn 2 years old, the parents should give them low‑fat or fat‑free milk, not whole milk. This reduces fat and cholesterol intake and helps prevent childhood obesity. B. Toddlers should have 4 to 6 oz of juice per day. Juices do not have the whole fiber that fruit has, and they contain sugar, so parents should limit their use. C. CORRECT: Serving sizes for toddlers should be about 1 tbsp of solid food per year of age, so 2‑year‑olds should have about 2 tbsp per serving. D. Popcorn poses a choking hazard to toddlers

. A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the client's pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply.) A. The client seems easily agitated. B. The client is nonadherent with coughing, deep breathing, and dangling. C. The client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr. D. The client reports tenderness in his right lower leg. E. The client's vital signs are heart rate 110/min, respiratory rate 20/min, temperature 37° C (98.6° F), and blood pressure 136/80 mm Hg.

A. Without more data, this finding alone does not suggest that the client has unrelieved pain. It might be his usual disposition, a result of hospitalization and surgery, or many other factors. B. CORRECT: Refusal to perform interventions that could increase his pain level (coughing, deep breathing) supports that the client has unrelieved pain. C. CORRECT: Acceptance of pain medication only at or beyond the maximum interval suggests that the client has pain between the time the effects of the previous dose subside and the new dose takes effect. D. Sudden tenderness or swelling in a lower extremity is more likely to suggest a new problem, such as deep‑vein thrombosis. E. CORRECT: Elevated blood pressure and pulse rate without elevated temperature or other signs of distress support that the client has unrelieved pain