Basic Physical Care - ML8

When placing an indwelling urinary catheter in a female client, the nurse should advance the catheter how far into the urethra? 2″ (5 cm) 8″ (20 cm) 6″ (15 cm) ½″ (1 cm)

2″ (5 cm) In a female client, the nurse should advance an indwelling urinary catheter 2″ to 3″ (5 to 7.5 cm) into the urethra. In a male client, the nurse should advance the catheter 6″ to 8″.

A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is most appropriate for the nurse-manager to take? Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process. Explain to the primary nurse that a 6-week orientation is standard. Meet with the new nurse and question the new nurse about deficits in performance. Meet with the new nurse and the primary nurse and help set up an additional week of orientation.

Meet with the new nurse and the primary nurse and help set up an additional week of orientation. The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation does not mean that a nurse is not competent or that there are deficits in performance. Although a 6-week orientation may be standard, orientation periods should be individualized to meet the needs of the staff as well as provide the best client outcomes. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete the orientation as efficiently as possible.

The nurse is measuring a client for thigh high antiembolism stockings. The client's thigh measurements are outside the guidelines for available sizes. What is the next action by the nurse? Notify the provider. Place knee high antiembolism stockings. Place the largest thigh high stockings available. Use the client's calf measurements to determine the size.

Notify the provider. If a client's thigh measurements are outside the guidelines for available thigh high antiembolism stockings, the nurse should notify the provider. The client may require custom fitted stockings or some other option for deep vein thrombosis prevention. Improperly fitted stockings are uncomfortable and may cause the client harm, therefore the nurse would not place the next size available or stockings based on the calf measurement. The nurse would not place knee high antiembolism stockings as this would require a provider's order.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? Eat a high-carbohydrate diet. Bathe daily. Move from the bed to the wheelchair every 2 hours. Shift your weight every 15 minutes.

Shift your weight every 15 minutes. The client who is wheelchair-bound with a spinal cord injury should be taught to make small weight shifts, lifting off the sacral area every 15 minutes. This decreases the risk of pressure ulcer formation. Bathing daily promotes skin cleanliness, but by itself will not prevent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates promotes good skin integrity. Moving from the bed to the wheelchair every 2 hours is not desirable because the client should not spend excessive amounts of time in bed. Pressure sores can develop in less than 2 hours.

A nurse documents a fraudulent wound assessment with the intent to increase the client's length of stay. What type of legal action is the nurse at risk for with fraudulent documentation? Select all that apply. a jail sentence a fine decrease in pay loss of nursing license job termination

a fine a jail sentence loss of nursing license job termination Falsification of documentation is a felony. Felonies carry fines and a jail sentence. Any nurse convicted of a felony loses the license to practice. The nurse will need to face criminal actions, not a change in pay.

These pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first? a pale 6-month-old with a frequent cough and audible wheezing a lethargic 15-month-old with pink cheeks whose parent reported temperature of 38.4°C (101.2°F) a crying 3-year-old whose parent is holding a cloth on the child's head covering a scalp laceration a quiet 2-year-old with nasal flaring who is sitting in a tripod position

a quiet 2-year-old with nasal flaring who is sitting in a tripod position The nurse identifies the nasal flaring and particularly the tripod position as indications of respiratory distress. This pediatric client needs rapid assessment and intervention and will be seen first. The other pediatric clients are not in immediate danger and will be seen as soon as possible by a healthcare professional.

The nurse is writing a medication order that a health care provider provided by telephone. Which should be included when writing the order? Select all that apply. code status medication ordered medication dosage date the order is written client allergies route of administration

date the order is written medication dosage route of administration medication ordered When writing a verbally received order, the medication needs to be included in the order so the pharmacy and nurse know what medication the health care provider ordered. The date needs to be included so there is a record of when the order was written. The medication dosage needs to be included so the pharmacist knows how much to dispense and the nurse knows how much to give the client. The route of administration needs to be included so the pharmacist knows what dosage form to dispense and the nurse knows by what route to administer the medication. The code status and allergies are important for the nurse to know, but they are not included when writing a medication order.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include ground beef patties. fresh orange slices. steamed broccoli. ice cream.

ground beef patties. Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

A nurse must apply an elastic bandage to a client's ankle and calf. The nurse should apply the bandage beginning at the client's ankle. lower foot. knee. lower thigh.

lower foot. An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee will not promote venous return.

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what? nonmaleficence informed consent pro-choice self-determination

nonmaleficence Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question.

A client's blood test results are: white blood cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which goal is most important for this client? prevent infection promote rest promote fluid balance prevent injury

prevent infection The client's dangerously low WBC count puts the client at risk for infection. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position? side-lying on the affected side supine semi-Fowler side-lying on the unaffected side

semi-Fowler A hyphema is the presence of blood in the anterior chamber of the eye. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as penetrating injury from a small bullet or pellet, or indirectly, such as from striking the forehead on the pavement during an accident. The client is treated by bed rest in a semi-Fowler position to assist gravity in keeping the hyphema away from the optical center of the cornea.

A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply. the nursing instructor the physician the assigned nurse the student nurse the dietician

the student nurse the nursing instructor the assigned nurse The student nurse, nursing instructor, and staff nurse are held to the same standard of care. The tube placement should be confirmed by radiology. The physician and dietician were not involved with the tube placement and following the standard of care with a radiology placement confirmation.

A nurse is planning staffing for a nursing unit in which the primary need of the clients is learning how to manage their health problems. Which combination is the ideal mix of staff for this unit? three registered nurses (RNs) one RN and two licensed practical/vocational nurses (LPNs/VNs) one LPN/VN and two unlicensed assistive personnel (UAPs) one RN, one LPN/VN, and one UAP

three registered nurses (RNs) The ideal staffing for a nursing unit focused on client teaching and learning is to have three registered nurses. It is within the scope of practice for the RN to assess, plan, implement, coordinate, and evaluate client learning. It is not within the scope of practice for LPNs/VNs and UAP to provide client teaching.

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action? to regulate the suction pressure to clear secretions from the tubing to lubricate the outside of the suction catheter to loosen the client's thick, tracheal secretions

to clear secretions from the tubing The picture shows a nurse inserting the suction catheter in a container of water. The hole on the catheter is then occluded creating suction. The water is used to clear the catheter and tubing of secretions. The tubing does not need to be primed or lubricated. The catheter removes the secretions but does not loosen them.

Professional regulations and laws that govern nursing practice are in place for which reason? to ensure that enough new nurses are always available to ensure that practicing nurses are of good moral standing to limit the number of nurses in practice to protect the safety of the public

to protect the safety of the public Governing bodies, professional regulations, and laws are in place to protect the public by ensuring that nurses are accountable for safe, competent, and ethical nursing practice. The other options do not describe accurately the role and responsibility of the governing bodies and the regulations and laws of nursing.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager? The nurse-manager only needs to be informed of the incident when the nurse-manager reports to work on the next scheduled day. Because the nurse-manager is off duty and not accountable for incidents that occur in their absence, the nurse-manager need not be notified. Although the nurse-manager is off duty and not responsible for what happened, the nursing supervisor would call the nurse-manager only if time permits. The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible.

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible. None of the other choices accurately reflect the nurse--manager's accountability in this situation.

When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which outcome indicates that the client is following instructions? There is no odor present. The skin around the stoma is red. The seal around the stoma is intact. The urine is a deep yellow.

The seal around the stoma is intact. If the appliance becomes too full, it is likely to pull away from the skin completely or to leak urine onto the skin; thus if the seal is intact, the client is emptying the appliance regularly. The skin around the seal should not be red or irritated, which could indicate a leak. There will likely be an odor from the urine. Deep yellow urine indicates that the client should be increasing fluid intake.

A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply. The student nurse is responsible for the student nurse's actions. The student nurse is held to the same standard of care as a nurse. The student nurse is not responsible for knowing the facility's policy and procedures. The student can practice as an employee during clinical experiences. The nursing instructor can be liable if the assignment is above the student's competency.

The student nurse is responsible for the student nurse's actions. The student nurse is held to the same standard of care as a nurse. The nursing instructor can be liable if the assignment is above the student's competency. Student nurses are responsible for their actions and are held to the same standard of care as a nurse. The nursing instructor can be liable if the student assignment is above the student's competency. Students cannot practice as employees during an educational clinical experience. Students are responsible for being familiar with hospital policy and procedures.

The nurse is helping to prepare a client for nonemergency surgery. What should the nurse do? Inform the client about the risks of the surgery to be performed. Verify the client understands the informed consent form. Explain the surgical procedure. Obtain informed consent from the client.

Verify the client understands the informed consent form. The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications, and that consent for the surgery is truly voluntary.

The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply. Wear a protective gown when in the client's room. Wear sterile gloves when providing care. Wash hands with soap and water. Wear a particulate respirator. Cleanse hands with alcohol-based hand sanitizer.

Wash hands with soap and water. Wear a protective gown when in the client's room. C. difficile is an organism that has developed very resistant and highly morbid strains. Universal precautions, most importantly handwashing, wearing personal protective gear, and modest use of antibiotics, are critical actions for stopping the spread. C. difficile is not spread via the respiratory tract; therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores of C. difficile; soap and water must be used. Sterile gloves are not needed to provide care; clean gloves may be worn.

The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply. List symptoms of peanut allergy. Food labels on baked items are the only labels that need to be read. Carry EpiPen autoinjector at all times. Wear a medic alert bracelet. Identify ways to manage allergy while dining out.

Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times. Wearing a medic alert bracelet allows others to be alerted of the allergy. Listing symptoms of the allergy makes the client aware of the allergic reaction if symptoms are being experienced. Identifying ways to manage allergies while dining out allows the client to be safe from a potential reaction. All food labels should be read not only baked items. The EpiPen autoinjector should be carried at all times in case it needs to be administered because of an allergic reaction.

A client has a tumor of the posterior pituitary gland. The nurse planning the client's care would include which interventions? Select all that apply. Restrict fluids. Place on a calorie-restricted diet. Weigh the client daily. Measure urine specific gravity. Monitor intake and output.

Weigh the client daily. Measure urine specific gravity. Monitor intake and output. The pituitary gland is divided into the anterior and posterior sections with each section secreting specific hormones. Tumors of the posterior pituitary gland can lead to diabetes insipidus because of deficiency of vasopressin, also called antidiuretic hormone (ADH). Decreased ADH reduces the kidneys' ability to concentrate urine, resulting in excessive urination, thirst, and fluid intake. To monitor fluid balance, the nurse would weigh the client daily, measure urine specific gravity, and monitor intake and output. The nurse would also encourage fluids to keep intake equal to output and prevent dehydration. The posterior pituitary does not have food or caloric implications; thus, a calorie-restricted diet is not needed.

The nurse gives a client an oral narcotic analgesic medication to treat postoperative pain. Which follow-up assessment most clearly indicates that the treatment was effective? Within 40 minutes the client breathes slowly with eyes closed. Within 10 minutes the client is moving down the hall. Within 30 minutes the client says that the pain is reduced. Within 20 minutes the client is reading with a relaxed posture.

Within 30 minutes the client says that the pain is reduced. To evaluate the effectiveness of medications, the nurse assesses for indications of pain at the time of the onset of action. Oral narcotic agents have a typical onset of action within 30 minutes of administration. The strongest indication of pain control is a client statement that the pain has decreased. The other situations could occur while the client continues to experience pain.

The nurse at an outpatient surgical clinic witnesses client signatures. When obtaining signatures, which clients are able to sign their own consent for a procedure/surgery? Select all that apply. a 72-year-old widow with dementia who needs a mastectomy for cancer removal a 16-year-old who is obtaining an elective breast reduction for back pain relief a 62-year-old with macular degeneration who is ordered a routine colonoscopy a married 17-year-old who requires a cholecystectomy for relief of nausea and pain a 7-year-old who needs an open reduction internal fixation (ORIF) of the right arm

a 62-year-old with macular degeneration who is ordered a routine colonoscopy a married 17-year-old who requires a cholecystectomy for relief of nausea and pain There are many factors for the nurse to consider when evaluating whether a client can consent to surgery. These include being mentally ill or disabled; a minor; under the influence of alcohol, drugs, or medication; in labor; under great stress or in pain at the time of consent; in a semi-conscious state. The 7- and 16-year-old are minors, whereas the 17-year-old is married and an emancipated minor and able to give consent. Having difficulty seeing due to macular degeneration does not preclude the ability to have the consent read and then provide consent. Depending upon the severity of the dementia, the client will need to be evaluated for competence before independently providing consent.

After completing initial assessment rounds, which client should the nurse discuss with the health care provider (HCP) first? a client admitted for lower extremity vasculitis and wound care who is requesting more pain medication before the next dressing change in 2 hours a client who had a right total knee replacement 2 days ago and now is reporting constipation and abdominal discomfort a client who was admitted from the emergency department last evening after a blow to the head who is now vomiting and confused as to time and place a client who returned from abdominal surgery last evening and now has a dime-sized bright red spot on the dressing

a client who was admitted from the emergency department last evening after a blow to the head who is now vomiting and confused as to time and place Any change in level of consciousness (vomiting, severe headache that is not improving or is getting worse, memory changes, confusion, irritability, change in pupils) should be immediately reported to the HCP and further evaluated, especially in a client with head trauma. The nurse should mark a circle around the amount of drainage on a dressing after surgery so it can be monitored and reported to the HCP if it grows in size, but a dime-sized spot is not an immediate priority. Constipation and abdominal discomfort after surgery require attention but are not priority. Obtaining proper pain medication in order to promote wound care and healing must be addressed with the HCP but it is not the first priority.

The charge nurse is assessing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in droplet precautions? Select all that apply. a client with a positive staphylococcus wound culture a client with bacterial meningitis a client with a critically low white blood cell count an older adult client with influenza a client receiving antibiotics for a fever after surgery

a client with bacterial meningitis an older adult client with influenza Droplet precautions are used for clients with bacterial meningitis and influenza. The client with a positive staphylococcus wound culture needs contact precautions. The client receiving antibiotics for a fever after surgery will not require precautions. The client with the low white blood cell count will need neutropenic precautions.

Which client would benefit from the application of warm moist heat? a client with a recently sprained joint a client with a suspected malignancy a client with appendicitis a client with low back pain

a client with low back pain Direct application of warm moist heat would benefit a client with low back pain because the heat relaxes muscle spasms. Heat should not be applied to a client who has appendicitis because it can lead to rupture of the appendix and peritonitis. Ice is applied to recently sprained joints to help decrease edema. Applying heat to the area of a suspected malignancy can increase blood flow to the tumor and promote nourishment of the cancer cells.

When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is appropriate? administering fluids to the client having the client take nothing by mouth until the gag reflex has returned placing the client on bed rest assessing the client for the presence of any metal implants

administering fluids to the client A client that receives an MRI with contrast will need to have fluids offered to facilitate kidney excretion of the contrast medium. There is no need to numb the client's throat for this procedure so the client's gag reflex should not be affected. There is no need to restrict the client's activity. The nurse should assess for the presence of metal implants prior to the MRI, not after.

A nurse is completing an admission fall assessment with an adult client. What are important nursing considerations to determine a high risk for falls? Select all that apply. systolic blood pressure > 180mmHg urinary urgency benzodiazepine medication anticoagulant medication advanced age

advanced age urinary urgency benzodiazepine medication Fall risk factors include advanced age due to changes in balance, urinary elimination symptoms such as urgency and the need to get to the bathroom more frequently. The use of benzodiazepines can cause the client to feel dizzy and lose balance. The use of anticoagulants is a consideration after a fall. Clients with low blood pressure are considered at risk for falls related to potential dizziness.

The nurse is reviewing a client's daily labs. Which lab report would concern the nurse related to the client's risk for skin breakdown? WBC potassium albumin sodium

albumin The laboratory tests are all within normal limits with the exception of the sodium and albumin level. While the sodium level is slightly low, the albumin level is significantly low with a normal level of 3.5-5.0 mg/dL. Additionally, albumin is a much more important indicator of the nutritional status and risk for skin breakdown than the remainder of the laboratory studies.

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine? serum potassium level lymphocyte count albumin level CBC differential

albumin level Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge their nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

Which client is most likely to exhibit dehydration? a 21-year-old man with profuse diaphoresis after a game of football an 8-month-old infant with persistent diarrhea for 24 hours a 60-year-old man with pneumonia and a temperature of 101°F (38.3°C) a 75-year-old woman who has been placed on NPO status 8 hours before surgery

an 8-month-old infant with persistent diarrhea for 24 hours Infants and elderly persons have the greatest risk of fluid-related health problems. An infant's body weight is 70% to 80% water content. An infant who is ill and has had persistent diarrhea for 24 hours will quickly lose a significant amount of fluid and electrolytes if the diarrhea is not stopped and replacement fluids given.Healthy young adults have a higher tolerance for fluid loss and can quickly regain their fluid balance when fluids are lost through normal activity.The 75-year-old woman who was placed on NPO status before surgery is not likely to develop a fluid volume deficit within 8 hours, unless there are other fluid conditions present that would precipitate fluid loss.The 60-year-old client with pneumonia and a fever should be monitored for a fluid deficit, but he is not as likely to develop one as a client who is actively losing fluids through diarrhea.

A nurse-manager must include which items as part of the personnel budget? anticipated overtime payments for staff computers for staff use office supplies for secretarial use videos for staff education

anticipated overtime payments for staff Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Any expense or single item of equipment costing more than $500 is part of the capital budget. Office supplies and videos are part of the operating budget.

A nurse is preparing to teach a client recovering from an anaphylaxis reaction about the prevention and management of reactions. What should the nurse include in the teaching? Select all that apply. monitor daily weight administer emergency medications until symptoms are severe how to administer emergency medications antigens that should be avoided take vital signs every day

antigens that should be avoided how to administer emergency medications The client should know what antigens should be avoided to prevent future anaphylaxis reaction. The client should know how to administer emergency medications in case of a reaction. Vital signs do not need to be taken every day. Daily weight monitoring does not need to be done. Emergency medications should be administered immediately to prevent symptoms from getting severe.

A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu. Which item would be appropriate for the client to order? Select all that apply. apple juice pudding cream soup tea broth

apple juice broth tea A clear liquid diet includes foods that are clear (that you can see through) and are liquid at room temperature. Apple juice, broth, and tea are clear. Pudding and cream soup would not meet the criteria of clear liquids. Select all that apply.

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? advocating for the client by ordering Meals on Wheels 5 days a week asking the physician to write an order for home skilled nursing assessments and interventions notifying the American Cancer Society (Canadian Cancer Society) of the client's diagnosis asking an occupational therapist to evaluate the client at home

asking the physician to write an order for home skilled nursing assessments and interventions Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for home healthcare. The American Cancer Society (Canadian Cancer Society) often sponsors support groups, which are helpful when the person is ready. However, contacting this organization would break client confidentiality, and even with the client's consent does not take precedence over ensuring proper home healthcare. Advocating for Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation.

A client in a long-term care facility refuses to take oral medications. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurse's statement constitutes which legal tort? assault battery right to refuse care negligence

assault Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow the client time to talk, and then determine if the client will take the medications. If the client still won't take the medications, the nurse should document this refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

A client admitted to the mental health unit has exhibited physical behaviors that put him and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of what? negligence withdrawal malpractice battery

battery Battery is intentional and wrongful physical contact with a person that entails an injury or offensive touching. Performing treatment without permission or receiving informed consent from the client might constitute both assault and battery. Judgments of battery suits have been based on the application of restraints to confused clients. Negligence and malpractice must result in harm to the client, and harm is not established in this scenario. The nurse is not withdrawing care.

A primiparous woman has just given birth to a term infant. What topic should the nurse teach the client about first? breastfeeding sudden infant death syndrome (SIDS) infant bathing infant sleep-wake cycles

breastfeeding Breastfed infants should eat within the first hour of life and approximately every 2 to 3 hours. Successful breastfeeding will likely require sustained support, encouragement, and instruction from the nurse. Information on SIDS, infant bathing, and sleep-wake cycles are also important topics for the new parent, but this information can be given at any time prior to discharge.

Which assessment factors would indicate a need for oropharyngeal suctioning? thin sputum, weak cough, and enlargement of the tonsils breathing rate of 36 breaths/min and noisy, gurgling respirations oxygen saturation levels of 95% and diaphragmatic breathing patterns auscultation of crackles in the lower lobes of the lungs

breathing rate of 36 breaths/min and noisy, gurgling respirations An increase in the breathing rate indicates hypoxia in the body. The signs of noisy, gurgling respirations indicate airway interference and the need for suctioning. Clients should be able to cough up thin sputum, and tonsil enlargement should not interfere. Crackles in lower lobes signify lung congestion, not airway impairment. Oxygen saturation levels of 95% are normal.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? by supplying a magic slate or similar device by placing the call button under the client's pillow by suctioning the client frequently by providing a tracheostomy plug to use for verbal communication

by supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which nutrient is most helpful for promoting endurance during sustained activity? water fat protein carbohydrate

carbohydrate The stored glucose of muscle glycogen is the major fuel during sustained activity. Glucose production slows as the body begins to depend on fat stores for glucose and fatty acids. Protein is not the body's preferred energy source. Fat is a secondary source of energy. Water is not an energy source, although sufficient water is required to engage in aerobic activity without causing dehydration.

Which theory of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? utilitarianism principle-based ethics deontology care-based ethics

care-based ethics Central to the care-based approach to ethics is the nurse's relationships with clients and the nurse's "being," or character and identity. Deontology concerns duty and obligation. Utilitarianism prioritizes the greatest happiness of the greatest number of people. Principle-based ethics is a framework that focuses on autonomy, non-maleficence/beneficence, and justice. Each prioritizes goals and principles outside the particularities of the nurse-client relationship.

A client who recently immigrated from Korea to the US or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time? giving the client the ordered as-needed pain medication checking vital signs and assessing for nonverbal indications of pain documenting that the client is resting quietly and denies pain calling a family member to obtain information about the client

checking vital signs and assessing for nonverbal indications of pain The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may result in inadequate intervention. Calling the family or giving pain medication isn't warranted at this time because the client denies pain and the nurse needs to obtain more information.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that only low doses of opioids are safe; higher doses may cause respiratory depression. a client who can fall asleep isn't in pain. pain medication should be given only when a client requests it. clients with terminal cancer may develop tolerance to opioids.

clients with terminal cancer may develop tolerance to opioids. Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an assessment. The nurse then informs the health care provider and the nursing supervisor about this incident and also completes an incident report. Which actions by the nurse indicates correct knowledge of handling an incident report? makes a copy of the incident report and places it in the client's records makes a copy of the incident report to give to the health care provider completes a full incident report mentions in the client's report that an incident report was completed

completes a full incident report An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record. The incident report is a legal document and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report.

Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? release of restraints as client symptoms improve evaluation of client response to restraint type assessment of client restraint location in relation to mental status completion of range of motion on limbs restrained

completion of range of motion on limbs restrained Any client assessment and subsequent decision making/judgment is in the scope of practice of the nurse. The unlicensed healthcare worker (UHW)/nursing assistant (NA) is able to complete the task of range of motion.

The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain? compressing it and then plugging it to establish suction irrigating it with normal saline connecting it to a drainage bag and clamping it off connecting it to low intermittent suction

compressing it and then plugging it to establish suction After emptying a Jackson-Pratt drainage bulb, the nurse should compress the bulb, plug it to establish suction, and then document the amount and type of drainage emptied. Irrigating a Jackson-Pratt drain is inappropriate because it could contaminate the wound. The Jackson-Pratt drain is not usually connected to wall suction. The purpose of the Jackson-Pratt drain is to remove bloody drainage from the deep tissues of the incision; clamping the drain would be counterproductive.

Values are known to affect a person's functional health. Which value may be related to the perception of health? Select all that apply. cooperation language intuition responsibility discipline

cooperation responsibility discipline Responsibility, discipline, and cooperation are values related to health perception and management. Language and intuition are not values related to health perception. Language and intuition are values related to cognition and perception. Language reflects cultural patterns of thinking in such areas as time, space, and world view.

A partner of a client diagnosed with Kaposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that the client "has just given up. I know with medication my partner will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving? denial stage bargaining stage depression stage anger stage

denial stage Denial, the avoidance of death's inevitability, is the first step of the grieving process. Anger, the most intense grief reaction, arises when people realize that a family member will die or has died. Bargaining occurs when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss expressed as profound sadness or deep suffering.

A nurse pulls the curtains before changing the dressing of the surgical wound on the abdomen of a post-surgical client. What value is served? accountability freedom dignity altruism

dignity The nurse values the dignity of the client and provides the client with privacy before changing the wound dressing. This incident does not serve the values of accountability, freedom, or altruism. A nurse values accountability when the nurse documents nursing care accurately and honestly. The nurse values freedom when the client's right to refuse treatment is honored. The nurse shows value for altruism when showing concern for the client's welfare.

A nurse-manager appropriately behaves as an autocrat in which situation? directing staff activities if a client experiences a cardiac arrest planning vacation time for staff evaluating a new medication-administration process identifying the strengths and weaknesses of a client-education video

directing staff activities if a client experiences a cardiac arrest In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care? protecting the client's safety by completing an incident or occurrence report counseling the person committing the abuse documenting the situation and providing support for the victim counseling the victim

documenting the situation and providing support for the victim The nurse must carefully and adequately document the assessment of the abused victim in the chart (not an incident or occurrence report). The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse is not qualified to counsel the abuser or the victim. The nurse should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.

The client has been prescribed vaginal cream for a yeast infection to be administered via a vaginal applicator. Which position would the nurse instruct the client to take for appropriate administration? low Fowler's position supine position dorsal recumbent position Sims' position

dorsal recumbent position The dorsal recumbent position (supine with the hips and knees bent) allows easy access to the vaginal orifice and proper placement for the medication. The other positions do not allow access to the vaginal orifice as the legs are closed.

Which nursing intervention is most important in preventing postoperative complications? bowel and elimination monitoring progressive diet planning early ambulation pain management

early ambulation Early ambulation is the most significant general nursing measure to prevent postoperative complications and has been advocated for more than 40 years. Walking the client increases vital capacity and maintains normal respiratory functioning, stimulates circulation, prevents venous stasis, improves gastrointestinal and genitourinary function, increases muscle tone, and increases wound healing. The client should maintain a healthy diet, manage pain, and have regular bowel movements. However, early ambulation is the most important intervention.

The nurse is providing cost-effective, evidence-based care health education to a client. Which choices are examples of cost-effective, evidence-based care? Select all that apply. education on current healthcare legislation education on beginning an exercise regime education on healthy dietary choices education on the client's extended health insurance plan education on the cost of the client's medical expenses

education on healthy dietary choices education on beginning an exercise regime Cost-effective, evidence-based care includes education on healthy lifestyle choices. Education on extended health insurance plans and medical expenses can be provided but is not considered cost-effective care. Education on healthcare legislation is not the priority.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? elevating the head of the bed 30 degrees maintaining a cool room temperature turning the client every 2 hours encouraging increased fluid intake

encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

A scrub nurse in the operating room has which responsibility? applying surgical drapes handing surgical instruments to the surgeon assisting with gowning and gloving positioning the client

handing surgical instruments to the surgeon The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies.

The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which complication? constipation rectal spasm urine retention hemorrhage

hemorrhage Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help prevent constipation.

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? identifying who will be responsible for making client care decisions deciding what type of dress code per nursing department will be implemented identifying salary ranges for various types of staff determining how planned absences, such as vacation time, will be scheduled so that all staff are treated fairly

identifying who will be responsible for making client care decisions Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organizations but they are not actually determined by the NCDS.

A hospitalized client is experiencing "fight versus flight," a stress-mediated physiologic response. As a result, the nurse should assess the client for which symptom? decreased mental acuity decreased arterial blood pressure increased urinary output increased blood glucose

increased blood glucose Responses to physiologic stress, such as hospitalization, surgery, or pain, are a result of catecholamine release, and specifically include increased heart rate and blood pressure, increased bronchiolar dilation, water retention and decreased urinary output, increased blood glucose, and increased mental acuity.

A client undergoing chemotherapy tells the nurse, "I don't want to get out of bed in the morning because I'm so tired." What information should the nurse include in the care plan? individually tailored exercise program. bed rest until chemotherapy is completed. weight lifting when not experiencing fatigue. education on the use of filgrastim.

individually tailored exercise program. An individualized exercise program will increase stamina and endurance. Weight lifting may be too vigorous. Filgrastim is used to increase white blood cells and is not applicable in this situation. Decreased hemoglobin and hematocrit predisposes the client to fatigue due to decreased oxygen availability. Bed rest causes muscle atrophy, adding to fatigue, and can contribute to deep vein thrombosis (DVT).

The nurse is making rounds and observes a client who is unconscious (see figure). The unlicensed assistive personnel (UAP) has just turned the client from lying on her back and raised the side rail next to the bedside stand. Before raising the side rail on the opposite side, the nurse should: ask the UAP to add a pillow under the right arm. inspect the skin at pressure points from the back-lying position. assist the UAP in moving the client closer to the head of the bed. elevate the head of the bed to 30 degrees.

inspect the skin at pressure points from the back-lying position. The client is positioned correctly in the side-lying position. The pillows support the client's joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client's skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.

The nurse started a peripheral intravenous line in a client's left forearm. What should the nurse include in the documentation? Select all that apply. date intravenous catheter placed location where intravenous access placed size of the intravenous catheter condition of the site type of tape used to stabilize the intravenous catheter

location where intravenous access placed size of the intravenous catheter date intravenous catheter placed condition of the site Documentation should include location where intravenous access was placed, the size of the intravenous catheter, date the intravenous catheter was placed, and the condition of the site after the intravenous catheter is placed. Tape is not used to stabilize the intravenous catheter. A stabilization device is used.

What finding indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? increase in muscle tone prevention of bone demineralization maintenance of joint mobility preservation of muscle mass

maintenance of joint mobility The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone.

Which nursing intervention is appropriate for a client with an arm restraint? applying the restraint loosely to prevent pressure on the skin monitoring circulatory status every 2 hours positioning the restrained arm in full extension tying the restraint to the side rail

monitoring circulatory status every 2 hours A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

The nurse is planning care for a client postoperatively to prevent pressure ulcers. Which interventions should the nurse include in the plan of care? Select all that apply. turning every 1-2 hours placing sequential compression devices keeping linens dry monitoring nutritional status elevating the head of the bed

monitoring nutritional status turning every 1-2 hours keeping linens dry Nurses must be alert to the potential for pressure ulcers in clients postoperatively due to pain and sedation, which can both limit client movement. While sequential compression devices are preventative for deep vein thrombosis, this is not an intervention to prevent pressure ulcers. Elevating the head of the bed may increase the risk for friction and shear if the client slides in the bed. Turning every 2 hours and keeping linens dry will help with prevention of pressure ulcers. Nutritional status with protein and calories plays a factor in skin integrity and is important to monitor as an intervention for the prevention of pressure ulcers.

An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures the right leg and right wrist. The nurse finding the client states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? negligence battery collective liability comparative negligence

negligence The position of the client's bed indicates negligence, a general term that denotes conduct lacking in due care. Collective liability stems from cooperation by several manufacturers in a wrongful activity. Comparative negligence holds the injured parties accountable for their fault in the injury. Battery involves harmful or unwarranted contact with the client.

A nurse takes informed consent from a client scheduled for abdominal surgery. Which is the most appropriate principle behind informed consent? protects the client's right to self-determination in health care decision making helps the client to make a living will regarding future health care required helps the client refuse treatment that he or she does not wish to undergo provides the client with in-depth knowledge about the treatment options available

protects the client's right to self-determination in health care decision making Informed consent protects the client's right to self-determination in healthcare decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? oral axillary tympanic rectal

rectal When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

A client says to the nurse, "My intravenous line hurts." The nurse assesses the client's peripheral intravenous line and suspects phlebitis. What assessment data confirm the nurse's suspicion? Select all that apply. edema above the insertion site redness respiratory distress pain around the infusion site warmth

redness pain around the infusion site warmth edema above the insertion site Redness, warmth, pain, and edema are all signs and symptoms of phlebitis. Respiratory distress is a sign of an air embolus.

The nurse is placing patches on both eyes of client with detachment of the retina. What is the expected outcome of patching? reduced rapid eye movements decreased irritation caused by light entering the damaged eye protection of the injured eye from infection minimized eye strain on the uninvolved eye

reduced rapid eye movements Patching the eyes helps decrease random eye movements that could enlarge and worsen retinal detachment. Although clients with eye injuries frequently are light sensitive, and preventing infection is important, the specific goal is to reduce rapid eye movements. Using the uninvolved eye would not cause eye strain, but random movements of one eye will involve the other eye.

The nurse is instituting a falls prevention program. Which personnel should be involved in the program? Select all that apply. housekeeping services client unlicensed assistive personnel registered nurses family members insurance providers

registered nurses unlicensed assistive personnel housekeeping services family members client Client safety is a priority for the client, the client's family, and all of the personnel working on this unit. All of these persons must be engaged in using strategies to prevent falls. The insurance provider does not need to be involved in developing a falls program.

A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should respond to the client by understanding that in the Asian culture which is the intended outcome of acupuncture? Acupuncture: promotes tranquility. purges evil spirits. restores the balance of energy. blocks nerve pathways to the brain.

restores the balance of energy. Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.

The client has aching, weakness, and a cramping sensation in both of the lower extremities while walking. To promote health and maintain the client's level of activity, the nurse should suggest that the client try: golfing. cross-country skiing. riding a stationary bike. jogging.

riding a stationary bike. In this case, the exercise prescription needs to be individualized because walking causes discomfort. To maintain the level of activity and decrease venous congestion, riding a stationary bike is another appropriate exercise behavior. Use of a stationary bike provides a non-weight-bearing exercise modality, which allows a longer duration of activity.Jogging and cross-country skiing are weight-bearing activities. In addition, cross-country skiing involves a cold environment, and maintaining warmth is essential in promoting arterial blood flow and preventing vasoconstriction.Golfing is a good activity, but it is not typically considered an exercise that causes aerobic changes in the body.

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? impaired circulation shearing forces localized pressure friction

shearing forces Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

Which is appropriate for the nurse to include in a plan for the prevention of pressure ulcers? systematic skin assessment at least once per shift encouraging the client to sit up as much as possible daily skin cleaning with soap and hot water gentle massage of bony prominences every shift

systematic skin assessment at least once per shift The best treatment for a pressure ulcer is prevention. If a client has been determined to be at risk for developing a pressure ulcer, a systematic skin assessment should be conducted at least once per shift. Other preventive measures include daily gentle cleaning of the skin and avoiding harsh soaps and hot water, which are damaging to the skin. Massage of bony prominences is not done because it can increase damage to the underlying tissue. The client should be encouraged to change position at least every 2 hours to avoid pressure on any one area for a prolonged period.

A client is recovering from an abdominal-perineal resection. To promote wound healing after the perineal drains have been removed the nurse should encourage the client to: take sitz baths. use a heating pad on the area. shower daily. apply moist dressings to the area.

take sitz baths. Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients find them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry.A shower will not adequately clean the perineal area.Moist dressings may promote wound contamination and delay healing.A heating pad applied to the area for longer than 20 minutes may cause excessive vasodilation, leading to congestion and discomfort.

A client is being transferred from the recovery room to the medical surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit? Select all that apply. names of all surgeons participating in the surgery fluids infusing including rate and type of fluid name of insurance provider current vital signs amount of blood loss type of surgery

type of surgery current vital signs amount of blood loss fluids infusing including rate and type of fluid Transfer reports must include information about the client's surgery, all current treatments and medications, vital signs, including pain level, fluid status including blood loss, and current IV infusions. It is not necessary to identify the surgeons who were present during the surgery or report the name of the insurance provider.

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client? Nurses: work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. touch the client, which increases their exposure to radiation. are at greater risk from the radiation because they are younger than the mother. work with many clients and could carry infection to a client receiving radiation therapy, if exposure is prolonged.

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years.

The nurse is assessing the pain level in a client who typically gives a stoic response to describing the pain. Which comment from this client is expected? "This pain is killing me." "I've got to see a health care provider (HCP) right away." "I can't go on in pain like this any longer." "Enduring pain is a part of God's will."

"Enduring pain is a part of God's will." Although individuals differ in their response to pain, the most likely attitude of a client who typically responds to pain stoically, is to endure pain as a part of God's will, and to delay requesting pain medication. The nurse can validate the client's response and respect his or her choice about receiving pain medication.

The nurse is completing discharge teaching with a client who had a long hospital stay. The client gives the nurse a handmade sweater for the personal nursing care. What is the best response by the nurse? Select all that apply. "I appreciate the gift but it not appropriate for me to take a personal gift." "Thank you for recognizing my work, I will enjoy wearing this sweater." "I cannot take this gift while I am at work." "Maybe I can meet you for coffee next week." "My hospital has a policy that does not allow a nurse to accept gifts."

"I appreciate the gift but it not appropriate for me to take a personal gift." "My hospital has a policy that does not allow a nurse to accept gifts." The nurse can explain the hospital policy and appropriateness of the nurse client relationship. The responses of "thank you for recognizing my work, I will enjoy wearing this sweater," "I cannot take this gift while I am working," and "maybe I can meet you for coffee next week," enter into the personal life of the nurse and client. The nurse client relationship does not encourage socializing with clients.

A client with newly diagnosed chronic obstructive pulmonary disease (COPD) presents to the clinic for a routine examination. The nurse teaches the client strategies for preventing airway irritation and infection. Which statement by the client best indicates that teaching was successful? "I should avoid using powders." "I'm glad I only need to get the flu vaccine to prevent respiratory illnesses." "I should use products with aerosol sprays." "I only need to avoid crowds during flu season."

"I should avoid using powders." There are many considerations when a client is diagnosed with COPD. A client with COPD should avoid exposure to powders; dust; and smoke from cigarettes, pipes, and cigars. The client should stay away from crowds and should avoid aerosol sprays as a precaution. The client should also obtain immunizations against pneumococcal pneumonia as well as influenza. A combination of measures is needed to maintain the client's highest level of respiratory function.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? "I will administer the enema while lying on my left side with my right knee flexed." "I will administer the enema while lying on my right side with my left knee flexed." "I will administer the enema while lying on my back with both knees flexed." "I will administer the enema while sitting on the toilet."

"I will administer the enema while lying on my left side with my right knee flexed." Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

The nurse is teaching a client how to manage a nosebleed. What instruction should the nurse give the client? "Tilt your head backward, and pinch your nose." "Sit down, lean forward, and pinch the soft portion of your nose." "Blow your nose gently with your neck flexed." "Lie down flat, and place an ice compress over the bridge of the nose."

"Sit down, lean forward, and pinch the soft portion of your nose." The client should assume a sitting position and lean forward. Firm pressure should be applied to the soft portion of the nose for approximately 10 minutes. Tilting the head backward can cause the client to swallow blood, which can obscure the amount of bleeding and also can lead to nausea. Ice compresses may be applied, but the client should not lie flat. Blowing the nose is to be avoided because it can increase bleeding.

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching? "I can have oatmeal, custard, and tea." "Today I can have apple juice, chicken broth, and vanilla ice cream." "I will have orange juice, farina, and coffee." "For breakfast I will choose pineapple juice, a bran muffin, and milk."

"Today I can have apple juice, chicken broth, and vanilla ice cream." A bland, full-liquid diet may include some fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as orange juice, coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods.

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response? "It is always a good idea to rest quietly after surgery, which will help minimize further pain." "Why don't you decide about activity after you return from recovery?" "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." "The physician will probably order you to lie flat for 24 hours."

"Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." To prevent venous stasis and improve muscle tone, circulation, and respiratory function, the client should be encouraged to move around after surgery. Pain medication will be administered to permit movement. Early ambulation with associated pain management reduces postoperative risk, and all other answers do not reflect this.

The nurse is educating a client who works with chemicals on immediate emergency care in the event of eye exposure. Which statement reflects correct teaching by the nurse? "You need to treat both eyes by flushing with water even if only one has been chemically exposed." "You should not attempt to do anything at home - come directly to the emergency department." "You can flush your eyes briefly with sterile water to try to remove the chemical." "You should flush your eyes for about 15 minutes with tap water to remove the chemical."

"You should flush your eyes for about 15 minutes with tap water to remove the chemical." The client who works with chemicals should be taught emergency care of the eyes in the event of chemical exposure. If one or both eyes are exposed, the client should irrigate the eyes for approximately 15 minutes with tap water to try to remove the chemical (sterile water is not required for flushing). Waiting until the client gets to the emergency department would delay care that could prevent more extensive injury to the eyes. There is no need to irrigate both eyes if only one is exposed; the client should be careful to not let the water run into the unaffected eye in case of chemical exposure in this way.

The nurse would most likely expect to manage a percutaneous feeding tube as part of daily care for which client? 65-year-old client who has bilateral upper extremity amputations 2-year-old child with an autism spectrum disorder and behavioral disturbances 90-year-old client with dysphagia following a stroke 20-year-old client who is a paraplegic

90-year-old client with dysphagia following a stroke A percutaneous feeding tube is inserted through the abdominal wall and into the stomach or intestine and is used to give medications and long-term enteral nutrition. This device is usually placed when there is difficulty with swallowing because of neurologic or anatomic disorders and can help prevent aspiration. Of the clients listed, the 90-year-old client with dysphagia (difficulty swallowing) subsequent to a stroke is the most likely candidate. The client with bilateral upper extremity amputations may require assistance with feeding, but there is no information suggesting that the client is unable to take food by mouth. The client with paraplegia would not have feeding difficulty or dysphagia, as the lower extremities would be affected in this case. The child with an autism spectrum disorder would not need a feeding tube for behavioral disturbances.

The nurse was unsuccessful starting a peripheral intravenous line in the right forearm of a client with a history of a left axillary lymph node removal. What should the nurse do next? Set up for placement of a triple-lumen central venous catheter. Try to start the peripheral intravenous line in the left forearm. Ask another nurse to attempt to start a peripheral intravenous line. Notify the health care provider.

Ask another nurse to attempt to start a peripheral intravenous line. Another nurse needs to attempt to start an intravenous line. That nurse may be successful with starting the intravenous line. The nurse should not begin by notifying the health care provider. This action should only be performed if multiple attempts have been made to insert an intravenous line without success. The nurse will not set up for placement of a triple-lumen central venous catheter without notifying the health care provider and getting an order. The client should not have an intravenous line started in the left forearm because of the lymph node removal. The removal of lymph nodes increases the risk of lymphedema, which can lead to an infection.

A client admitted to the hospital for chemotherapy states that using a peppermint-scented candle at home to helps control nausea. Which interventions would the nurse plan to promote comfort for this client? Asking the physician to order a sedative for the client to use during chemotherapy Asking the client to try using peppermint oil in place of scented candles Telling the client she may use his scented candles Asking the physician to increase the client's anti-nausea medication

Asking the client to try using peppermint oil in place of scented candles Aromatherapy may affect the brain's limbic system, causing relaxation, evoking positive emotional memories, and decreasing the need for antiemetics. Such alternative therapies may increase a client's feeling of control over illness. Because this client associates positive feelings with the scent of peppermint, the nurse should encourage the client to continue using that scent, but should ask the client to use scented oil rather than a candle. Fire of any kind, even a candle, is a hazard in the hospital — especially when oxygen is being used. Increasing the client's nausea medication or ordering a sedative could cause dangerous adverse effects and wouldn't be best practice.

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When coaching the client about the diet, what should the nurse do first? Determine the client's knowledge level about cholesterol. Ask the client to name foods that are high in fat, cholesterol, and salt. Explain the importance of complying with the diet. Assess the client's and family's typical food preferences.

Assess the client's and family's typical food preferences. Before beginning dietary instructions and interventions, the nurse must first assess the client's and family's food preferences, such as pattern of food intake, lifestyle, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the following actions? All options must be used.

Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility. The nurse should first assess the client and then, if there is no acute injury, help the client get back into bed. The nurse must notify the HCP and the family of the client who fell and, finally, document the event on the client's health record.

On the day of surgery, a client has been breathing room air. The vital signs are normal, and the O2 saturation is 89%. What should the nurse do first? Administer oxygen by nasal cannula as prescribed at 2L per minute. Lower the head of the bed. Assist the client to take several deep breaths and cough. Notify the health care provider (HCP).

Assist the client to take several deep breaths and cough. Deep breathing and coughing help to increase lung expansion and prevent the accumulation of secretions in postoperative clients. An O2 saturation of 89% is not an unexpected or emergent finding immediately following surgery. Frequent coughing and deep breathing will likely quickly remedy an O2 saturation of 89% but will also effectively help to prevent atelectasis and pneumonia in the remainder of the postoperative period. It is not necessary to notify the HCP prior to intervening with coughing/deep breathing, and it is not appropriate to position this client with the head of bed lower because this would make it more difficult for the client to expectorate secretions. Oxygen may be necessary, but the nurse should assist the client to cough and deep breath first, in an attempt to improve his oxygenation and saturation.

A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do first? Insert an intermittent urinary catheter. Assist the client to the toilet to attempt to void. Encourage the client to increase oral fluid intake. Use an ultrasound bladder scanner to determine urine volume in the bladder.

Assist the client to the toilet to attempt to void. Urinary retention is common following abdominal surgery. The nurse should first assist the client to an anatomically comfortable position to void prior to resorting to other strategies such as catheterization. If the client is unable to void, the nurse can use a bladder scanner to determine the volume of retained urine, and then, if necessary, use an intermittent urinary catheter. While increasing fluid intake is important, it will not help the client void now.

A client had abdominal surgery 2 days ago and has copious drainage. The nurse uses Montgomery straps when changing the dressing. Which is the expected outcome of using these straps? Keep the client from touching the incision. Maintain pressure on the suture line. Prevent dehiscence. Avoid skin breakdown.

Avoid skin breakdown. While the client has copious drainage and requires frequent dressing changes, the nurse uses Montgomery straps to avoid removing the tape that is holding the dressing in place and thus preventing skin breakdown. The straps are not used to provide pressure on the incision and will not help prevent dehiscence. The straps are secured on the abdomen and would not prevent the client from touching the incision.

A nurse manager is making morning assignments for the nursing team. Which duties can be assigned to the nursing assistant/unlicensed worker? Select all that apply. repositioning a client on complete bed rest obtaining vital signs on a client being admitted to the unit teaching a client on an anticoagulant about using an electric razor totaling the intake and output for the entire unit Changing the linen of a client on a pressure releasing mattress transferring a client from the bed to the chair using a mechanical lift

Changing the linen of a client on a pressure releasing mattress transferring a client from the bed to the chair using a mechanical lift repositioning a client on complete bed rest totaling the intake and output for the entire unit The nursing assistant/unlicensed worker can assist the nurse in duties that do not require skilled nursing and nursing judgment. Changing linen, transferring a client using a mechanical lift, totaling the intake and output, and repositioning a client is in the scope of practice of the nursing assistant/ unlicensed worker. Skills that require a registered nurse include medication teaching and vital sign assessment on admission.

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse? Delegate the placement of compression stockings to the unlicensed assistive personnel (UAP). Measure the client for the appropriate sized compression stockings. Retrieve compression stockings from the supply room. Check the medical record for a provider's prescription for compression stockings.

Check the medical record for a provider's prescription for compression stockings. The application of compression stockings for a client in the postoperative period requires a healthcare provider's prescription. The nurse should check the medical record for the given prescription before proceeding with the placement of the compression stockings. Placement of compression stockings may be delegated to unlicensed assistive personnel (NAP) after properly measuring the client for the appropriate size. It is important to measure the client for the appropriate size stocking before retrieving the compression stockings from the supply room.

A postoperative client is experiencing urinary retention, and the nurse is inserting an indwelling catheter. Immediately, 750 mL of clear yellow urine is collected in the drainage bag. What should the nurse do next? Pinch the catheter to slow the flow of urine. Continue to drain the bladder until empty. Remove the catheter and document the output. Clamp the catheter for 20 minutes.

Clamp the catheter for 20 minutes. Taking a large amount of urine from the bladder over a short period of time puts the client at risk for hypovolemic shock. The other options would not prevent hypovolemic shock. The only way to gradually remove urine is to clamp and unclamp the catheter.

Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? Wear sterile gloves and a mask. Clean briskly around the site with alcohol. Remove the drain before cleaning the skin. Clean from the center outward in a circular motion.

Clean from the center outward in a circular motion. The nurse should move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and, because it evaporates, has no lasting effect on bacteria. The nurse should wear sterile gloves to prevent contamination but need not wear a mask.

The nurse is preparing to clean around a client's G-tube that was placed 1 week ago and change the gauze dressing. Based on the type of procedure, what type of precautions are needed? Sterile procedure, airborne precautions Clean procedure, universal precautions Clean procedure, contact precautions Sterile procedure, droplet precautions

Clean procedure, universal precautions Site care for a recently placed G-tube is a clean procedure, not a sterile procedure. Care should be taken not to introduce bacteria into the fresh site, but sterile gloves and sterile procedure is not necessary or recommended. Universal precautions are required, as the nurse will come into contact with blood and/or bodily fluids while cleaning around the G-tube. Droplet, contact, and airborne precautions are not indicated, because these are for a variety of infectious diseases such as methicillin-resistant Staphylococcus aureus, influenza, measles, meningitis and tuberculosis, not for wound care.

The nurse is caring for an unconscious intubated client with normal intracranial pressure. What should the nurse include in the care plan? Clean the mouth carefully, apply a thin coat of a water-based lubricant, and move the endotracheal tube to the opposite side daily. Turn the client with a drawsheet, and place a pillow behind the back and one between the legs. Monitor the oral temperature, keep the room temperature at 70°F (21.1°C), and place the client on a cooling blanket if the client's temperature is higher than 101°F (38.3°C). Position the client in the supine position with the head to the side and slightly elevated on two pillows.

Clean the mouth carefully, apply a thin coat of a water-based lubricant, and move the endotracheal tube to the opposite side daily. The nurse must clean the unconscious client's mouth carefully, apply a thin coat of water-based lubricant, and move the endotracheal tube to the opposite side daily to prevent dryness, crusting, inflammation, and parotitis. The unconscious client's temperature should be monitored by a route other than the oral (e.g., rectal, tympanic) because oral temperatures will be inaccurate. The client should be positioned in a lateral or semiprone position, not a supine position, to allow for drainage of secretions and for the jaw and tongue to fall forward. The client should not be dragged when turned, as may happen when a drawsheet is used. Care should be taken to lift the client's heels, buttocks, arms, and head off of the sheets when turning. Trochanter rolls, splints, foam boot aids, specialty beds, and so on-not just two pillows-should be used to keep the client in correct body position and to decrease pressure on bony prominences.

A client recovering from surgery needs to be ambulated in the room twice a day. For which reason should the nurse question the use of a gait belt when ambulating this client? Client is being treated for a wound infection. Client is recovering from abdominal surgery. Client needs minimal assistance to ambulate. Client has mild cognitive impairment.

Client is recovering from abdominal surgery. A gait belt is used to transfer and assist a client with ambulation. A gait belt should not be used on a client with an abdominal incision that would be present after abdominal surgery. A gait belt would not necessarily be required for a client with mild cognitive impairment. A gait belt would not be required for a wound infection. A client needing minimal assistance would be a reason to use a gait belt.

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? Client's vital signs and breath sounds Client's risk for falls Client's level of consciousness Client's nutritional status

Client's level of consciousness A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad. When administering a heat treatment, a nurse should always check the temperature of the heating unit and examine the client's skin for redness or irritation. Risk for falls, vital signs, and nutrition level are also important assessment areas, but they aren't the priority assessment for a client using a heating pad.

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention? Clients should be instructed to wash thoroughly with soap and water. Access to the area should be restricted. Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. All personnel should wear protective clothing, including a gown, gloves, and respiratory protection.

Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. Clients exposed to anthrax should place contaminated clothes in a plastic bag and mark the bag "contaminated." Wearing protective clothing, instructing exposed clients to wash thoroughly, and restricting access to the exposed area are appropriate actions to take in response to a bioterrorism threat.

What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day? Complete regular admission procedures. Provide detailed information on the procedure. Schedule the client for screening tests. Prepare for long-term care needs.

Complete regular admission procedures. Clients entering the hospital setting for outpatient surgery have regular admission procedures conducted by the nurse. Scheduling of screening tests and initial teaching is completed in the days prior to the surgery. Same-day surgery and discharge may require community-based follow-up but it generally does not require long-term care. Detailed information on the procedure will be provided by the physician performing the procedure.

A nurse is caring for a morbidly obese client who has undergone surgery for weight loss. The client reports pain 8/10 despite morphine sulfate 1 mg/hour continuous infusion being administered via a patient-controlled analgesia (PCA) pump. Which action will best protect the nurse from issues of liability? Provide the client with nonpharmacologic means of pain control Explain to the client that pain is expected with weight loss surgery Add morphine sulfate 1 mg/8 min IV as a client-administered dose to the continuous infusion Contact the health care provider with a request for a change in PCA

Contact the health care provider with a request for a change in PCA State Boards of Nursing and the provincial or territorial nursing regulatory bodies set acceptable standards for nursing for a particular state or Canadian province or territory. Practicing within those guidelines will protect the nurse from liability. A nurse has a legal responsibility to address and manage a client's pain. The nurse would recognize that morphine 1 mg/hour continuous intravenous infusion may not provide adequate pain control in a morbidly obese client. The best option to avoid liability issues regarding pain control would be to contact the health care provider to request a change in analgesia for this client. Offering nonpharmacologic means of pain control is appropriate, but fails to address the need for a change in PCA. Adding a self-administered dose of morphine sulfate via PCA without a health care provider prescription would be outside the scope of practice for a registered nurse. Explaining to the client that pain is to be expected does nothing to meet the legal responsibility the nurse has to manage a client's pain and increases a nurse's risk of liability.

The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process? Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. Ask her staff nurses to investigate discharge policies and procedures at other outpatient facilities and recommend changes. Ask the nurse-managers at the best facilities for their policies and procedures so she can adopt them. Ask the staff nurses to form a task force to review and revise discharge policies and procedures.

Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. Benchmarking is a good approach for the nurse-manager to take. Benchmarking is the process of comparing an organization's delivery of client care practices in one organization to those in the best health care organizations. Because the nurse-manager already has contacts at the best facilities, she's the most appropriate person to obtain the necessary information. The nurse-manager, however, shouldn't automatically change her policies and procedures to match those of the best facilities. Instead, she should evaluate the policies to determine which ones might be implemented at her facility. Then she and her staff should make appropriate recommendations for change. Asking her staff to form a task force is a good idea, but benchmarking saves time and effort and enables the nurse-manager to obtain information from excellent resources.

The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the next action by the nurse? Contact the surgeon to answer the client's question. Answer the client's question regarding the surgery. Ask the circulating nurse to inform the surgeon of the client's question. Contact the anesthesiologist and request a delay of surgery.

Contact the surgeon to answer the client's question. If a client verbalizes questions regarding a surgery, then informed consent cannot be given. To have informed consent, the surgeon performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. The surgeon is responsible for ensuring that informed consent is obtained. The nurse would contact the surgeon to answer the client's questions prior to the start of the procedure, not answer the client's questions. Informed consent would be obtained prior to the client being transported to the operating room; therefore, having the circulating nurse convey the information is inappropriate. Although it may be necessary to delay the surgery, it would be most appropriate to contact the surgeon to answer the client's question.

The nurse finds a small fire in the linen closet. Which action(s) should the nurse take to minimize the consequences of the fire? Select all that apply. Use a fire extinguisher. Rescue clients who are at risk. Step on burning embers to extinguish them. Contain the fire. Activate the alarm. Leave closet door open to facilitate access to the fire.

Contain the fire. Rescue clients who are at risk. Activate the alarm. Use a fire extinguisher. RACE is an acronym used to remember these actions in the case of a fire. Rescue: assist anyone in immediate danger and help get them to a safe area as fast as possible. Alarm: alert others by activating any available alarm system. Contact 911 to report the location of the fire and alert on-site personnel. Contain: confine the fire as soon as possible by closing windows and doors behind you during evacuation. Extinguish: only attempt to put out the fire if it is small, if you have the proper equipment, and if it is safe to do so yourself. Retrieve the nearest fire extinguisher and follow the "P.A.S.S." procedure:P = Pull the pin breaking the plastic sealA = Aim at the base of the fireS = Squeeze the handles togetherS = Sweep from side to side. The nurse should not stamp on burning embers to try to extinguish them, as they may ignite the nurse's clothing. The nurse will need to complete an incident report, but only after the fire has been dealt with.

While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next? Notify the physician that the wound may be infected. Apply normal saline solution to keep the wound moist. Prepare the client for debridement of the suture line. Continue to monitor the suture line, and document findings.

Continue to monitor the suture line, and document findings. During the fibroplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This normal occurrence requires the nurse to continue to monitor the suture line. There is no evidence of wound dehiscence or necrotic tissue. There is also no indication that the wound is open or needs to be kept moist.

The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse should tell them? Dehydration may prolong the dying process. Hydration is used only in extreme situations of dehydration. The health care provider (HCP) will make the decision regarding hydration therapy. Dehydration is expected during the dying process.

Dehydration is expected during the dying process. Dehydration is an expected event within the dying process. Hydration may be used in any situation of dehydration as long as it is within the client and family's wishes. Rehydrating the client may actually prolong the dying process. Decisions about treatment are made with the family.

A staff nurse on a busy pediatric unit would like to function effectively in the role of a leader. Which action would the nurse employ to be a leader? Follow unit and hospital policy in daily situations. Tell the staff on the unit how to do their job effectively based on current research and relevant experience. Ask the nursing administration for the authority to make decisions that will affect the staff. Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills.

Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills. A leader does not have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager's formal power and authority within the organization are detailed in the job description. An autocrat is not interested in guiding or encouraging staff or in being an effective role model. A manager derives authority by virtue of the position within an organization.

A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks if the nursing assistant has been validated on obtaining fingerstick glucose readings. The nursing assistant does not have the skill validated, but has observed it many times and reports confidence in the ability to perform the skill. What should the nurse do? Provide the nursing assistant with an article on the procedure. Go with the nursing assistant into the client's room, and validate the nursing assistant's ability to perform the procedure. Give the nursing assistant the glucose meter, and let the nursing assistant perform the fingerstick. Perform the fingerstick glucose testing instead of the nursing assistant.

Go with the nursing assistant into the client's room, and validate the nursing assistant's ability to perform the procedure. The nurse should validate the nursing assistant's ability to perform the fingerstick glucose procedure. The nursing assistant may not perform the procedure without having her skills validated by actually performing the procedure. Providing reading material about the procedure is not enough. If the nurse performs the procedure, she forfeits the opportunity to validate the nursing assistant's skills, and therefore underutilizes the nursing assistant.

A nurse is reluctant to provide care at an accident scene. Which legal definition is true regarding the provision of nursing care? Malpractice is failure to perform professional duties that result in client injury. Negligence is intentional failure to act responsibly or deliberate omission of a professional act. Scope of practice involves general guidelines that define nursing. Good Samaritan laws are designed to protect the caregiver in emergency situations.

Good Samaritan laws are designed to protect the caregiver in emergency situations. Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection. Failure to stop would constitute an issue. Malpractice involves the failure to perform professional duties; it may involve omissions of important care measures or performing care measures that are not appropriate in the situation. Negligence is failure to act professionally. Scope of practice includes specific guidelines of professional conduct.

The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a client on bed rest. What should the nurse do? Explain that massage is effective because it improves blood flow to the area. Reinforce the UAP's use of this intervention over the bony prominences. Inform the UAP that massage is even more effective when combined with lotion during the massage. Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

Instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Massaging areas that are reddened due to pressure is contraindicated because it further reduces blood flow to the area. The UAP should not massage the bony prominences or use lotion on the area. Massage does improve circulation and blood flow to muscle areas; however, because the area is reddened, the client is at risk for further skin breakdown.

An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take? Apply an abdominal binder. Splint the abdomen with a pillow and call the surgeon. Reinforce the existing dressing with another dressing. Lift the dressing to assess the wound.

Lift the dressing to assess the wound. The client probably has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should take which precaution? Minimize urinary catheter use and duration of use in all clients. Use sterile technique when providing catheter care. Clean the periurethral area with antiseptics. Ensure that clients who are incontinent have indwelling urinary catheters.

Minimize urinary catheter use and duration of use in all clients. Minimizing urinary catheter use and duration of use in all clients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, older adults, and clients with impaired immunity, will reduce the opportunity for infection. The nurse should avoid the use of urinary catheters for clients who are incontinent; a bladder training program and frequent use of the toilet are preferred; external catheters may be used if necessary in incontinent clients. The nurse should not clean the periurethral area with antiseptics; cleansing the meatal surface during daily bathing or showering is appropriate. Using sterile technique to help to reduce CAUTI is not necessary. Hand hygiene immediately before and after insertion or any manipulation of the catheter device or site is sufficient.

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). What should be the nurse's first response? Send the client to surgery. Make a note on the client's record. Call the operating room to cancel the surgery. Notify the anesthesiologist.

Notify the anesthesiologist. The nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L (5.8 mmol/L) places the client at risk for arrhythmias when under general anesthesia. It is not the role of the nurse to cancel surgery. The nurse should not automatically send a client with abnormal laboratory findings to surgery because the procedure may be canceled. Once the client is inside the operating room and sterile supplies have been opened up for the procedure, the client is usually charged. The nurse should call ahead of time to communicate the abnormal laboratory result instead of noting the finding on the client's record. The information on the record should not be reviewed until after the client has been transported to the operating room and the supplies have been opened.

The nurse is preparing a client for surgery. Although the client can speak English, English is the client's second language. The client has completed high-school level education. When the nurse asks the client what type of surgery is scheduled, the client is unable to provide an answer. What should the nurse do next? Explain the procedure in detail to the client, and assess the client's understanding. Continue to follow the preoperative procedures required to prepare the client for surgery. Document the client's response in the electronic medical record. Notify the health care provider that the client cannot explain the scheduled surgery.

Notify the health care provider that the client cannot explain the scheduled surgery. The nurse should ask the health care provider to explain the surgery to the client again and ensure the client understands the procedure and the risks. If necessary, the nurse can call an interpreter. It is the role of the health care provider to explain the surgical procedure, not the nurse. The nurse cannot continue to prepare the client until the health care provider has explained the surgery and the client agrees to proceed. The nurse should then document the client's response and nurse's action after notifying the health care provider of the need to reexplain the procedure to the client.

What should the nurse do to ensure safety for a hospitalized blind client? Request that the client stays in bed until the nurse can assist. Require that the client has a sitter for each shift. Orient the client to the room environment. Keep the side rails up when the client is alone.

Orient the client to the room environment. The priority goal of care for a client who is blind is safety and preventing injury. The initial action is to orient the client to a new environment. Taking time to identify the objects and where they are located in the room can achieve this goal. It is unrealistic to have someone stay with the client at all times or for the client to stay in bed until the nurse can assist. Using side rails creates unnecessary barriers and may be a safety hazard.

A client is being discharged with nasal packing in place. What should the nurse instruct the client to do? Perform frequent mouth care. Gargle every 4 hours with salt water. Sneeze and cough with mouth closed. Use normal saline nose drops daily.

Perform frequent mouth care. Frequent mouth care is important to provide comfort and encourage eating. Mouth care promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When sneezing and coughing, the client should do so with the mouth open to decrease the chance of dislodging the packing. Gargling should not be attempted with packing in place.

Three victims with gunshot wounds are brought to the emergency department. The nurse should take which action to preserve forensic evidence on the clients' clothing? Request that a law enforcement officer observe the removal of clothing. Place all wet clothing in a plastic bag. Place each item of clothing in a separate paper bag. Cut around blood stains to remove clothing.

Place each item of clothing in a separate paper bag. Preserving forensic evidence is essential for investigative purposes following injuries that may have resulted from criminal activity. The nurse places each item of clothing in a separate paper bag and labels it; wet clothing is hung to dry. Paper bags are used because moisture can collect in plastic bags and alter the evidence. The nurse does not cut or otherwise unnecessarily handle clothing, particularly clothing with evidence such as blood or body fluids. It is not necessary to have law enforcement personnel present at this time, but the nurse should document all nursing care and use quotes around the clients' exact words where possible; documentation will become a part of the clients' medical records and can be subpoenaed for subsequent investigation.

When providing oral hygiene for an unconscious client, the nurse must perform which action? Place the client in a side-lying position. Clean the client's tongue with gloved fingers. Place the client in semi-Fowler's position. Swab the client's lips, teeth, and gums with lemon glycerin.

Place the client in a side-lying position. An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration.

Which item must the nurse consider when positioning a client for tracheal suctioning? Ensure that the client's neck is flexed. Maintain the head in a hyperextended position. Position in a semi-Fowler's position. Position in low-Fowler's position.

Position in a semi-Fowler's position. The semi-Fowler's position is the correct position for suctioning a client. The other answers are incorrect based on incorrect positioning of client for suctioning. The neck should be in neutral position.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied? Elevate the client's legs while out of bed. Remove elastic stockings once per day and observe lower extremities. Teach the client isotonic leg exercises. Order a second pair of stockings to be rotated each day.

Remove elastic stockings once per day and observe lower extremities. Elastic stockings are used to promote venous return and prevent deep vein thrombosis. A client with peripheral vascular disease and diabetes is at risk for skin breakdown, and the nurse must therefore remove the stockings once per day to observe the condition of the skin. Elevating the client's legs while out of bed and teaching isometric leg exercises will promote venous return. However, after applying the stockings, the nurse's priority should be the client's skin integrity. Ordering a second pair of stockings would not be a priority.

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply. Report signs of redness or inflammation at the site. Cleanse the port with alcohol wipes. Call the health care provider (HCP) for a temperature above 100° F (37.8° C). Place the IV bag on a table level with the client's arm. Wear sterile gloves to change the fluids.

Report signs of redness or inflammation at the site. Call the health care provider (HCP) for a temperature above 100° F (37.8° C). Cleanse the port with alcohol wipes. When intravenous (IV) therapy must be administered in the home setting, teaching is essential. Written instructions, as well as demonstration and return demonstration help reinforce key points. The client and/or caregiver is responsible for adhering to the established plan of care that includes the treatment plan, monitoring plan, potential for complications, expected outcome/s, potential adverse effects, and plan for communicating with the HCP. Periodic laboratory testing may be necessary to assess the effects of IV therapy and the client's progress. The client should report signs of redness or inflammation that could indicate infection, and also report an elevated temperature. Prior to changing the fluids, the caregiver should cleanse the port with alcohol wipes. It is not necessary to use sterile gloves; the IV bag should be elevated to promote gravity flow.

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: Report this finding to the nurse who is taking care of the client. Report this finding to the physician. Document the bruising and continue to assess the area over the next 72 hours. Report this finding to the Adult Protective Services (APS).

Report this finding to the Adult Protective Services (APS). Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS.

A hospitalized client is receiving pain medication. The nurse is providing instruction to the unlicensed assistive personnel (UAP) about the care of this client. Which task would be appropriate to delegate to the UAP? Ask client about pain level. Collaborate with the RN about what decreases the client's pain. Encourage client to increase fiber in the diet. Reposition the client for comfort.

Reposition the client for comfort. The UAP can do basic ADLs and vital signs. The UAP is not allowed to teach a client to increase fiber. The UAP cannot assess the client's pain level. The UAP does not collaborate in the development of a plan of care.

A nurse is caring for a client with a percutaneous feeding tube. The client has a prescription for 325 mg enteric coated aspirin to be given via the feeding tube once daily. How should the nurse give this medication? Add the tablet to the feeding tube whole, followed by a flush Request an alternate formulation Crush the tablet, mix with a small amount of water, and infuse into the feeding tube, followed by a flush Give the tablet by mouth

Request an alternate formulation The nurse must request an alternate formulation of this medication, as enteric coated medications cannot be given via feeding tube. Enteric coated tablets cannot be crushed to administer through the feeding tube, because altering the integrity of this type of medication is dangerous. The tablet cannot be added to the feeding tube whole as it will be too large and can occlude the tube, if it even fits in the opening whole. Giving the tablet by mouth would be a medication error, because it is prescribed to be administered via the feeding tube, and the client may not be able to safely take PO medications.

Entering a client's room, a nurse on the maternity unit sees a mother slapping the face of a crying neonate. Which action should the nurse take in this situation? Return the neonate to the nursery, inform the physician so the physician can thoroughly examine the neonate for injuries, and notify social services for assistance. Leave the room immediately, without the neonate, and notify the nursing supervisor. Confront the mother by asking her what she's doing and why. Return the neonate to the nursery and inform coworkers so they can monitor the mother's behavior.

Return the neonate to the nursery, inform the physician so the physician can thoroughly examine the neonate for injuries, and notify social services for assistance. The neonate's safety and protection is the first priority. The nurse should immediately return the neonate to the nursery and inform the physician of the neonate's abuse. By being the neonate's advocate, the nurse allows the physician to examine the neonate for injuries resulting from the incident. Social services should be notified. The neonate shouldn't remain in the room with the mother unsupervised. The nurse should follow the facility's policy and procedure for reporting suspected and actual child abuse. Although the incident may be part of the mother and neonate's revised care plan, it requires immediate intervention, not simple notification of coworkers. Confronting the mother doesn't provide for the neonate's safety.

A nurse is providing client care on a rehabilitation unit that has an increasingly diverse population. What nursing actions would be appropriate when providing care to clients? Select all that apply. Ask the client if they require any special diet or interventions while they are in the hospital. Review available information and health practices of the common cultures in that area. Keep in mind that clients may be members of multiple religious or cultural groups at the same time. Utilize family members to translate any medical information when explaining care to a client. Provide no special interventions as it is crucial to treat these clients the same as everyone else.

Review available information and health practices of the common cultures in that area. Ask the client if they require any special diet or interventions while they are in the hospital. Keep in mind that clients may be members of multiple religious or cultural groups at the same time. The ANA Code of Ethics for Nurses requires nurses to provide culturally competent care to clients. Clients may be members of multiple religious or cultural groups at the same time. Cultural diversity includes people of varying cultures, racial and ethnic origin, religion, language, physical size, gender, sexual orientation, age, disability, socioeconomic status, occupational status, and requires special nursing interventions and assessment in order to provide the best nursing care to these clients. Communication with the client is crucial to individualized and culturally competent care. Family members are not appropriate interpreters to use when explaining care to a client.

Which is the correct technique when the nurse is applying an elastic bandage to a leg? Increase tension with each successive turn of the bandage. Secure the bandage with clips over the area of the inner thigh. Start at the distal end of the extremity and move toward the trunk. Overlap each layer twice when wrapping.

Start at the distal end of the extremity and move toward the trunk. When applying an elastic bandage to a leg, start at the distal end and move toward the trunk in order to support venous return. Tension should be kept even and not increased with each turn to prevent circulatory impairment. Overlapping each layer twice when wrapping can also impair circulation. The clips securing the bandage should be placed on the outer aspect of the leg to avoid creating a pressure point on the other leg.

The nurse walks into a client's room to administer the 0900 medications and notices that the client is in an awkward position in bed. What should the nurse do first? Straighten the client's pillow behind the back. Give the client the medications. Check the client's name band. Ask the client to state his or her name.

Straighten the client's pillow behind the back. The nurse should first help the client into a position of comfort even though the primary purpose for entering the room was to administer medication. After attending to the client's basic care needs, the nurse can proceed with the proper identification of the client, such as asking the client his or her name and checking the armband, so that the medication can be administered.

A group of people arrives at the emergency department reporting extreme periorbital swelling, cough, shortness of breath, and tightness in the throat. They report that someone threw a bomb that exploded at their feet. What is the best action by the nurse? Administer NAAK (Nerve Agent Antidote Kit). Take them to the decontamination area. Remove the clients' clothes. Administer 2 liters of oxygen.

Take them to the decontamination area. The best action by the nurse is to take the clients to the decontamination area to be decontaminated. That way the agent is no longer infiltrating the clients nor are the other individuals in the emergency room exposed to the decontaminating agent. Once decontamination is completed, then other actions can be administered such as administering oxygen and/or NAAK. But the first priority is to stop the decontaminating agent from continuing to impact the victims by completing decontamination.

A nurse is giving a presentation to retirement home residents on fall prevention and injury reduction. Which priority would be the most important? Teach about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness. Explain the importance of a health professional evaluating gait and assessing for motor deficits. Discuss instability and effective use of ambulatory aids to stabilize the base of support. Discuss decreasing activity and favoring the use of wheelchairs, rather than mobility aids, to reduce the incidence of falls.

Teach about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness. Sitting for a few minutes is the most appropriate strategy to discuss to help maintain safety and reduce falls. Reliance on wheelchairs rather than mobility aids will result in weakening of the muscles and less strength and stability. The remaining actions would be important factors but not the immediate priority.

A client has a nursing diagnosis of Ineffective airway clearance related to retained secretions. When planning this client's care, the nurse should include which intervention? Improving airway clearance Suctioning the client every 2 hours Increasing fluids to 1500 ml/day Teaching the client how to deep-breathe and cough

Teaching the client how to deep-breathe and cough Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition, but this intervention does not address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning is not indicated unless other measures fail to clear the airway.

A nurse observes an LPN measuring a client's urine output from an indwelling catheter drainage bag. Which observation by the nurse ensures that the client's urine has been measured accurately? The LPN pours the urine into a graduated measuring container. The LPN pours the urine into a paper cup that holds approximately 250 mL. The LPN holds the Foley drainage bag up to eye level. The LPN uses the measuring markings on the Foley drainage bag.

The LPN pours the urine into a graduated measuring container. The only means to measure urine output accurately is to use a container that has specific markings for measuring liquid. The other options would not provide an accurate measure of urine output.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? The client rinses around the clean incision site, using gauze squares moistened with normal saline. The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. The client rinses around the clean incision site, using gauze squares moistened with tap water. After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing.

The client rinses around the clean incision site, using gauze squares moistened with normal saline. To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline - not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of non-raveling material instead of cotton-filled gauze squares.

Which consideration is the most important when performing tracheotomy suctioning? Suctioning should be done routinely and frequently to prevent accumulation of secretions. Oxygen should be provided after each suctioning episode if desaturation occurs. The client should be hyperoxygenated, then suctioned for 10 to 15 seconds. Fluid intake should be limited to reduce the amount of secretions produced.

The client should be hyperoxygenated, then suctioned for 10 to 15 seconds. The most important aspect is to ensure the client is hyperoxygenated to increase oxygen saturation levels. Then suctioning should be limited to 10-15 seconds. This helps to prevent desaturation so that breathing is not compromised. It is not enough to apply oxygen if desaturation occurs. Suctioning should be done when necessary, not as a routine. Fluid intake is increased to help liquefy the secretions.

A client in a long-term care facility has signed a form stating that the client does not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case? The client should be resuscitated if the client experiences respiratory arrest. The wishes of the client's family should be followed. Pharmacologic interventions should not be initiated. The client should be treated with antibiotics for pneumonia.

The client should be treated with antibiotics for pneumonia. The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.

Which action by the client indicates that the client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client uses diaphragmatic breathing in the lying, sitting, and standing positions. The client takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. The client breathes in through the nose and out through the mouth. The client breathes in through the mouth and out through the nose.

The client takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. The correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? The nurse dries from finger tips down toward elbows. The nurse keeps hands lower than elbows while washing. The nurse uses at least 3 to 5 mL of liquid soap. The nurse dries from forearms up toward fingers.

The nurse dries from forearms up toward fingers. Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

Which example may illustrate a breach of confidentiality and security of client information? The nurse accesses client information on the computer at the nurse's station then logs off before answering a client's call bell. The nurse provides information over the phone to the client's family member who lives in a neighboring state. The nurse provides information to a professional caregiver involved in the care of the client. The nurse informs a colleague that the colleague should not be discussing client information in the hospital cafeteria.

The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether the client wants the family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach in confidentiality, while providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.