Evolve: Fundamentals Basics of Nursing Practice

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 1 The dosage is kept at a minimum. 2 Only a small part of the body is irradiated. 3 The client's physical condition is not a risk factor. 4 Nutritional environment of the affected cells is a risk factor.

2 Only a small part of the body is irradiated.

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? 1 Malice 2 Tort law 3 Malpractice 4 Case law

3 Malpractice

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? 1 Soap 2 Time 3 Water 4 Friction

4 Friction

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? 1 Procedures used to implement client care. 2 Sequence of steps used to meet the client's needs. 3 Activities employed to identify a client's problem. 4 Mechanisms applied to determine nursing goals for the client.

2 Sequence of steps used to meet the client's needs.

It is appropriate for the nurse to pull up on the client's skin, release it, and determine if the skin returns immediately to its original position to assess for: 1 Pain tolerance 2 Skin turgor 3 Ecchymosis formation 4 Tissue mass

2 Skin turgor

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1 Limit the client's fluid intake. 2 Teach the client how to exercise the legs. 3 Encourage use of the incentive spirometer. 4 Maintain the knee gatch position at an angle

2 Teach the client how to exercise the legs.

An older client is apprehensive about being hospitalized. The nurse realizes that one of the stresses of hospitalization is the unfamiliarity of the environment and activity. How can the nurse best limit the client's stress? 1 Use the client's first name. 2 Visit with the client frequently. 3 Explain what the client can expect. 4 Listen to what the client has to say.

3 Explain what the client can expect.

A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that the legal term that best describes this situation is: 1 False threats 2 Assault and battery 3 False imprisonment 4 Breach of confidentiality

3 False imprisonment

A nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." How should the nurse respond? 1 "Your wish will be respected." 2 "Why do you want to be called Doctor?" 3 "Residents here call one another by their first names." 4 "Wouldn't it be better if the others do not know you are a doctor?"

"Your wish will be respected."

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain: 1 Abduction. 2 Adduction. 3 Traction. 4 Elevation

1 Abduction.

A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? 1 At the time of admission 2 After a relative gives permission 3 When the client talks about future plans 4 As soon as the client's transfer has been approved

1 At the time of admission Preparation of clients for discharge to their own home or to a nursing home should begin on the day of admission. The client gives permission for transfer to a nursing home

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next: 1 Bending and then straightening their knees 2 Bending at the waist and then straightening the back 3 Placing one foot in front of the other and then leaning back 4 Placing pressure against the client's axillae and then raising their arms

1 Bending and then straightening their knees The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs the back is protected from injury.

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? 1 Cognitive response 2 Emotional response 3 Perceptual response 4 Physical response

1 Cognitive response

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate when the patient is in the emergency department? 1 Core rewarming with warm fluids 2 Ambulation to increase metabolism 3 Frequent oral temperature assessments 4 Gastric tube feedings to increase fluid volume

1 Core rewarming with warm fluids

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiological change does the nurse attribute the decreased blood pressure? 1 Dilation of blood vessels 2 Decreased response of chemoreceptors 3 Decreased strength of cardiac contractions 4 Disruption of cardiac accelerator pathways

1 Dilation of blood vessels Paralysis of the sympathetic vasomotor nerves after administration of a spinal anesthetic results in dilation of blood vessels, which causes a subsequent decrease in blood pressure.

A 2-g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? 1 Discuss the diet with the client and family. 2 Tell the client why salty foods should not be eaten. 3 Explain the dietary restriction to the client's visitors. 4 Ask the dietitian to teach the client and family about sodium restrictions

1 Discuss the diet with the client and family.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? 1 Elevate HOB 30-45 degrees. 2 Decrease flow rate at night. 3 Check for residual daily. 4 Irrigate regularly with warm tap water.

1 Elevate HOB 30-45 degrees.

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications

1 Encouraging daily physical exercise

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? 1 Exploring 2 Reflecting 3 Refocusing 4 Acknowledging

1 Exploring

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for: 1 Falls 2 Impaired cognition 3 Imbalanced nutrition 4 Impaired gas exchange

1 Falls The client is at risk for falls related to the leg prosthesis and history of syncope. There is no evidence or contributing factors in the patient scenario of the other nursing problems.

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? 1 Heredity 2 Hypertension 3 Cigarette smoking 4 Diabetes mellitus

1 Heredity Heredity refers to genetic makeup and cannot be changed. Cigarette smoking is a lifestyle habit that involves behavior modification. Hypertension and diabetes mellitus are risk factors of coronary artery disease that can be controlled with diet, medication, and exercise.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? 1 Keeps the area free of microorganisms. 2 Confines microorganisms to the surgical site. 3 Protects self from microorganisms in the wound. 4 Reduces the risk for growing opportunistic microorganisms.

1 Keeps the area free of microorganisms. Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound applies to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

A nurse applies an ice pack to a client's leg for 20 minutes. The cold application will cause what physiological effect? 1 Local anesthesia 2 Peripheral vasodilation 3 Depression of vital signs 4 Decreased viscosity of blood

1 Local anesthesia Cold reduces the sensitivity of pain receptors in the skin. In addition, local blood vessels constrict, limiting the amount of edema and its related pressure and discomfort. Local blood vessels constrict. Local cold applications do not depress vital signs. Local cold applications do not affect blood viscosity directly.

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? 1. Older adults 2. Adolescents 3. Young children 4. Middle-aged adults

1 Older adults

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's Hierarchy of Needs does this nursing action address? 1 Safety 2 Self-esteem 3 Physiological 4 Interpersonal

1 Safety

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention? 1 Sitting quietly with the client. 2 Telling the client that crying is not helpful. 3 Suggesting that the client play a board game. 4 Recommending how the client can change this situation

1 Sitting quietly with the client. Sitting quietly with the client conveys the message that the nurse cares and accepts the client's feelings; this helps to establish trust. Telling the client that crying is not helpful negates feelings and the client's right to cry when upset. Distraction (suggesting that the client play a board game) closes the door on further communication of feelings. After a trusting relationship has been established, the nurse can help the client explore the problem in more depth.

A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? 1 Spread the client's feet away from each other. 2 Move the client on the count of three. 3 Instruct the client to flex the muscles of the internal girdle. 4 Stand close to the client when assisting with the move

1 Spread the client's feet away from each other. Spreading the feet apart widens the base of support. A wide base of support lowers the center of gravity, thereby increasing stability

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer? 1 The client should have been turned regularly. 2 Older clients frequently develop pressure ulcers. 3 The nurse is not responsible to the client's family. 4 Nurses should respect a client's right not to be moved.

1 The client should have been turned regularly. Clients should change position at least every two hours to prevent pressure ulcers. The nurse should not deviate from this standard of practice because of the cognitively-impaired client's refusal to move. The nurse was negligent for not changing the client's position. Although pressure ulcers may occur, nursing care must include preventive measures. The family is included in the health team. When a capable client refuses necessary health care, the nurse should provide health teaching to promote understanding of the treatment plan. If the client makes an informed decision after an explanation, then the client's rights must be respected; however, this client is cognitively impaired.

When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands that this finding: 1 is a normal occurrence. 2 may indicate atherosclerosis. 3 can be attributed to aortic disease. 4 indicates lymphedema

1 is a normal occurrence.

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? (Select all that apply.) 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

1 Assessment of skin turgor 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? (Select all that apply.) 1 Dry cerumen 2 Tears in the tympanic membrane 3 Difficulty hearing high-pitched voices 4 Decrease of hair in the auditory canal 5 Overgrowth of the epithelial auditory lining

1 Dry cerumen 3 Difficulty hearing high-pitched voices Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier

To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) 1 Encourage ambulation 2 Give sips of ginger ale 3 Auscultate bowel sounds 4 Provide a straw for drinking 5 Offer an opioid analgesic

1 Encourage ambulation 3 Auscultate bowel sounds Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? (Select all that apply.) 1 Oral temperature 98.2° F 2 Apical pulse 88 beats per minute and regular 3 Respiratory rate of 30 per minute 4 Blood pressure 116/78 mm Hg while in a sitting position 5 Oxygen saturation of 92%

1 Oral temperature 98.2° F 2 Apical pulse 88 beats per minute and regular 4 Blood pressure 116/78 mm Hg while in a sitting position

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? (Select all that apply.) 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 Guided imagery

1 Prayer 2 Hypnosis 4 Aromatherapy 5 Guided imagery

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? (Select all that apply.) 1 Whole grains 2 Cooked fruit and vegetables 3 Nuts and seeds 4 Lean red meats 5 Milk and eggs

1 Whole grains 2 Cooked fruit and vegetables 5 Milk and eggs

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill? 1 Knowledge of the grieving process 2 Personal feelings about terminal illness 3 Recognition of the family's ability to cope 4 Previous experience with terminally ill clients

2 Personal feelings about terminal illness To be effective in a relationship with a client, the nurse must know and understand personal feelings about terminal illness and death.

A client with cancer is informed that the chemotherapy is no longer working and that death is inevitable. Keeping in mind Kübler-Ross's stages of death and dying, place the following nursing interventions that are most appropriately associated with each stage in order from the stage of denial to acceptance. 1. Provide maximal comfort measures. 2. Avoid confronting the client. 3. Redirect negative feelings constructively. 4. Help the client identify realistic versus unrealistic goals. 5. Help the client celebrate the simple pleasures in everyday life.

1.Avoid confronting the client. 2.Redirect negative feelings constructively. 3.Help the client identify realistic versus unrealistic goals. 4.Help the client celebrate the simple pleasures in everyday life. 5.Provide maximal comfort measures. DABDA During the denial stage, the nurse needs to avoid confronting the client's behavior because denial at this early stage is a self-protective mechanism. It is unwise to confront a client's coping mechanism because it leaves the client unprotected. During the anger stage, the nurse needs to accept the client's behavior and redirect negative feelings constructively. During the bargaining stage, the client generally seeks to achieve a goal. The nurse needs to help the client be realistic in this endeavor. During the depression stage, the nurse should encourage the client to engage in simple pleasures, such as sitting in the sun. During the acceptance stage, the nurse should provide comfort measures based on needs and desires.

Place each step of the nursing process in the order that it should be used. a. Identify goals for care. b. Develop a plan of care. c. State client's nursing needs. d. Implement nursing interventions. e. Obtain client's nursing history.

1.Obtain client's nursing history. 2. State client's nursing needs. 3. Identify goals for care 4. Develop a plan of care. 5. Implement nursing interventions.

A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: 1 In the axillae. 2 On the hands. 3 On the right side. 4 On the side that the client prefers.

2 On the hands.

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. The nurse identifies that the UAP is providing false reassurance when the UAP states: 1 "I agree; I think you should get a divorce." 2 "Everything will be fine, just wait and see." 3 "You should be glad that you have such a loving family." 4 "In the scheme of things, you do not have a major problem."

2 "Everything will be fine, just wait and see."

A newly hired nurse, during orientation, is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1 "Let me get my preceptor." 2 "Wash your hands before and after any client care." 3 "Clean all instruments and work surfaces with an approved disinfectant." 4 "Ensure proper disposal of all items contaminated with blood or body fluids.

2 "Wash your hands before and after any client care."

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? 1 A statement that the nursing staff was not at fault because the client initiated the accident. 2 A listing of facts related to the incident as witnessed by the nurse. 3 The name of the nurse who was responsible for implementing the restraints. 4 The potential reasons why the restraints were not in place at the time of the fall.

2 A listing of facts related to the incident as witnessed by the nurse.

A client who has reached the stage of acceptance in the grieving process appears peaceful, but demonstrates a lack of involvement with the environment. How should the nurse address this behavior? 1 Ignore the client's behavior when possible. 2 Accept the behavior the client is exhibiting. 3 Explore the reality of the situation with the client. 4 Encourage participation within the client's environment.

2 Accept the behavior the client is exhibiting. Detachment is a coping mechanism that the client needs, especially when faced with the inevitability of death; the nurse should accept this behavior.

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to: 1 Hyperventilate the client with room air prior to suctioning. 2 Apply suction only as the catheter is being withdrawn. 3 Insert the catheter until the cough reflex is stimulated. 4 Remove the inner cannula before inserting the suction catheter

2 Apply suction only as the catheter is being withdrawn. Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection, and the catheter should only be inserted approximately 1 to 2 cm past the end of the trach tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary. Topics

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate: 1 Venous insufficiency 2 Arterial Insufficiency 3 Phlebitis 4 Lymphedema

2 Arterial Insufficiency Clients suffering from arterial insufficiency present with pale colored extremities when elevated and dusky red colored extremities when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny, thin, with decreased hair growth, and thickened nails. Clients suffering from venous insufficiency often have normal colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result from impaired flow of the lymphatic system.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? 1 Have the prescription renewed every 48 hours 2 Assess the client's condition every hour 3 Provide range of motion to the client's elbows every shift 4 Document output from the tube and catheter every two hours

2 Assess the client's condition every hour A restraint impedes the movement of a client; therefore, a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally do not need to be documented as frequently as every two hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.

A nurse who promotes freedom of choice for clients in decision-making best supports which principle? 1 Justice 2 Autonomy 3 Beneficence 4 Paternalism

2 Autonomy The principle of autonomy relates to the freedom of a person to form his or her own judgments and actions. The nurse promotes autonomy nonjudgmentally so as not to infringe on the decisions or actions of others

The nurse is caring for a client with a closed soft tissue injury. The nurse describes the injury as a/an: 1 Abrasion 2 Contusion 3 Laceration 4 Avulsion

2 Contusion Closed wounds are considered contusions and hematomas because the skin is not broken. Abrasions, lacerations, and avulsions are considered open because there is a break in the skin integrity.

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? 1 Anger 2 Denial 3 Bargaining 4 Depression

2 Denial Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions.

The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." The nurse determines that the client needs to be taught about the: 1 Need for home-delivered meals 2 Foods that meet basic nutritional needs 3 Effect of aging on the need for some foods 4 Need for meat at least once per day throughout life

2 Foods that meet basic nutritional needs

our days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? 1 Decreased blood supply 2 Impaired neural functioning 3 Perforation of the bowel wall 4 Obstruction of the bowel lumen

2 Impaired neural functioning Paralytic ileus occurs when neurological impulses are diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion

2 Lower the height of the enema bag. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1 Famotidine (Pepcid) 2 Methyldopa (Aldomet) 3 Ferrous sulfate (Feosol) 4 Levothyroxine (Synthroid)

2 Methyldopa (Aldomet) Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1 Limits had to be set to control the child's crying. 2 The child had a right to remain in the room with the other children. 3 The child had to be removed because the other children needed to be considered. 4 Segregation of the child for more than half an hour was too long a period of time.

2 The child had a right to remain in the room with the other children. Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated.

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1 Arrangements will be made by the client and the client's family. 2 The plan is formulated and implemented early in the client's care. 3 The rehabilitation is minimal and short term because the client will return to former activities. 4 Arrangements will be made for long-term care because the client is no longer capable of self-care

2 The plan is formulated and implemented early in the client's care.

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on: 1 Alternating sides. 2 The right side. 3 The side of the weakness. 4 The side of the client's choice.

2 The right side.

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1 Maintain the head of the bed at 35 degrees or less. 2 With the help of another staff member, use a drawsheet when lifting the client in bed. 3 Reposition the client at least every 2 hours and support the client with pillows. 4 At least once every 8 hours, perform passive range-of-motion exercises of all extremities

2 With the help of another staff member, use a drawsheet when lifting the client in bed.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk? 1 Eggs 2 Yogurt 3 Potatoes 4 Applesauce

2 Yogurt Yogurt, which contains calcium, is digested more easily because it contains the enzyme lactase, which breaks down milk sugar. Yogurt contains approximately 274 to 415 mg of calcium for an 8-oz container, depending on how it is prepared. Eggs contain approximately 22 mg of calcium. One potato contains approximately 7 to 20 mg of calcium, depending on how it is prepared. Eight ounces of applesauce contain approximately 3 mg of calcium.

Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1 Giving a back rub. 2 Cleaning a newborn immediately after delivery. 3 Emptying a portable wound drainage system. 4 Interviewing a client in the emergency department. 5 Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

2 Cleaning a newborn immediately after delivery. 3 Emptying a portable wound drainage system.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? (Select all that apply.) 1 Dyspnea 2 Flushed face 3 Chest pain 4 Increased pulse rate 5 Increased blood pressure

2 Flushed face 4 Increased pulse rate Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

The nurse recognizes that which are important components of a neurovascular assessment? (Select all that apply.) 1 2 Orientation 3 Capillary refill 4 Pupillary response 5 Respiratory rate 6 Pulse and skin temperature 7 Movement and sensation

2 Orientation 5 Respiratory rate 6 Pulse and skin temperature A neurovascular assessment involves evaluating of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluating of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.

What are the best ways for a nurse to be protected legally? (Select all that apply.) 1 Ensure that a therapeutic relationship with all clients has been established. 2 Provide care within the parameters of the state's nurse practice act. 3 Carry at least $100,000 worth of liability insurance. 4 Document consistently and objectively. 5 Clearly document a client's non-adherence to the medical regimen.

2 Provide care within the parameters of the state's nurse practice act. 4 Document consistently and objectively. 5 Clearly document a client's non-adherence to the medical regimen.

A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.) 1 feces. 2 blood. 3 semen. 4 urine. 5 sweat. 6 tears

2 blood. 3 semen

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? 1 Industry versus inferiority 2 Identity versus role confusion 3 Generativity versus stagnation 4 Autonomy versus shame/doubt

3 Generativity versus stagnation

A nurse is hired to work in a health care facility that has a complete computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says: 1. "More medication errors are made when this system is used." 2. "It is disappointing that nurses are not allowed to use this system." 3. "Client information is immediately available when this system is used." 4. "I will have less time to provide direct care to my clients with this system."

3 "Client information is immediately available when this system is used."

A client who is dying appears happy and tells a nurse a joke about the situation despite becoming sicker and weaker. What is the nurse's most therapeutic response? 1 "Why are you always telling jokes?" 2 "Your laughter is a cover for your fear." 3 "Does it help to joke about your illness?" 4 "The one who laughs on the outside cries on the inside."

3 "Does it help to joke about your illness?"

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 1 "Hospital policies should put a stop to this." 2 "Everyone should conform to the prevailing culture." 3 "Nontraditional approaches to health care can be beneficial." 4 "You are right because they may have a negative impact on people's health."

3 "Nontraditional approaches to health care can be beneficial." Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

A nurse speaking in support of the best interest of a vulnerable client reflects the nurse's duty of: 1 Caring. 2 Veracity. 3 Advocacy. 4 Confidentiality

3 Advocacy. The nurse has a professional duty to advocate for a client by promoting what is best for the client. This is accomplished by ensuring that the client's needs are met and by protecting the client's rights.

A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? 1 Have two nurses witness the client signing the operative consent form. 2 Ensure that the health care provider and the psychiatrist sign for the surgery because it is an emergency procedure. 3 Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. 4 Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit.

3 Ask the client to sign the operative consent form after the client has been informed of the procedure and required care.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? 1 Justice 2 Veracity 3 Autonomy 4 Beneficence

3 Autonomy The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence

3 Belonging

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1 Force urine to back up into the kidneys. 2 Suppress production of urine. 3 Cause the device to pull away from the skin. 4 Tear the ileal conduit

3 Cause the device to pull away from the skin.

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? 1 Airborne precautions 2 Droplet precautions 3 Contact precautions 4 Protective environment

3 Contact precautions Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms (MDRO) such as MRSA, stool infected with Clostridium difficle, draining wounds where secretions are not contained, or scabies.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as: 1 Vesicular 2 Bronchial 3 Crackles 4 Rhonchi

3 Crackles Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli.

A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? 1 Abrasion 2 Fracture 3 Crush injury 4 Incisional laceration

3 Crush injury

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1 Apathy 2 Euphoria 3 Detachment 4 Emotionalism

3 Detachment When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.

Which nursing behavior is an intentional tort? 1 Miscounting gauze pads during a client's surgery. 2 Causing a burn when applying a wet dressing to a client's extremity. 3 Divulging private information about a client's health status to the media. 4 Failing to monitor a client's blood pressure before administering an antihypertensive.

3 Divulging private information about a client's health status to the media.

What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? 1 Makes the skin more supple 2 Avoids drying the skin as does alcohol 3 Eliminates surface bacteria that may contaminate the culture 4 Provides a cooling agent to diminish the feeling from the puncture wound

3 Eliminates surface bacteria that may contaminate the culture Povidone-iodine exerts bactericidal action that helps eliminate surface bacteria that will contaminate culture results

An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. The nurse identifies that a factor of special concern when caring for this client is the client's: 1 Irritability in response to deprivation 2 Decreased ability to recall recent facts 3 Inability to maintain an optimal level of functioning 4 Gradual memory loss resulting from change in environment

3 Inability to maintain an optimal level of functioning

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1 A loss of skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions 3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties

3 Increased blood pressure and decreased hormone production With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.

A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take? 1 Notify the nurse manager of the unit. 2 Inform no one because all client information is confidential. 3 Inform the client's healthcare provider. 4 Alert the hospital security department because heroin is an illegal substance

3 Inform the client's healthcare provider. The fetus of a heroin-addicted mother is at risk for serious complications such as hypoxia and meconium aspiration. It is important to notify the healthcare provider of the client's heroin use, because this information will influence the care of the client and newborn.

A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? 1 Ask the pharmacist to provide a generic form of the medication. 2 Encourage the client to acquire the medication over the internet. 3 Inform the health care provider of the inability to afford the medication. 4 Suggest that the client purchase insurance that covers prescription medications.

3 Inform the health care provider of the inability to afford the medication.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident? 1 Exempt from any lawsuit because of the doctrine of respondeat superior 2 Totally responsible for the obvious negligence because of failure to report defective equipment 3 Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client 4 Exonerated, because only the hospital, as principal employer, is responsible for the quality and maintenance of equipment

3 Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client

A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 1 Relieve bronchial spasm. 2 Increase depth of respirations. 3 Loosen pulmonary secretions. 4 Expel carbon dioxide from the lungs.

3 Loosen pulmonary secretions. Percussion (chest physiotherapy) loosens pulmonary secretions by mechanical means. This is accomplished by vibrations over the lung fields on the client's posterior, anterior, and lateral chest. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? 1 Hepatitis C (HepC) 2 Influenza type B (HIB) 3 Measles, mumps, rubella (MMR) 4 Diphtheria, tetanus, pertussis (DTaP)

3 Measles, mumps, rubella (MMR) Individuals born after 1957 should receive one additional dose of MMR vaccine if they are students in postsecondary educational institutions. Currently there is no vaccine for hepatitis C. The HIB immunization is unnecessary. If the student received an additional DTaP at age 12, it is not necessary. A booster dose of tetanus toxoid (Td) should be received every 10 years.

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? 1 Eating beef and veal is prohibited. 2 Consumption of fish with scales is forbidden. 3 Meat and milk at the same meal are forbidden. 4 Consuming alcohol, coffee, and tea are prohibite

3 Meat and milk at the same meal are forbidden. Jewish dietary laws prohibit any combination of milk and meat at the same meal. The Hindu, not Jewish, religion prohibits the ingestion of beef and veal; many Hindus believe that the cow is sacred. Fish that have scales and fins are considered clean, and therefore allowed in the diet. Seventh Day Adventists, Baptists, Mormons, and Muslims prohibit some or all of these beverages.

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? 1 Emptying the unit is safer when it is half full. 2 Accurate measurement of drainage is facilitated. 3 Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. 4 Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound

3 Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. As drainage collects and occupies space, the original level of negative pressure decreases; the less the negative pressure, the less effective the drainage. A portable wound suction device is easy and safe to empty regardless of the amount of drainage in the unit. Drainage can be measured accurately by the calibrations on the unit or in a calibrated container after emptying. A one-way valve between the tubing and the collection chamber prevents drainage from entering the tubing and causing trauma to the wound.

A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? 1 Inform the client of the results. 2 Ensure that the results are placed in the client's medical record. 3 Notify the client's healthcare provider of the results. 4 Request the test be re-done to ensure accuracy.

3 Notify the client's healthcare provider of the results.

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1 Multipara in active labor 2 Middle-aged woman with substernal chest pain 3 Older adult male with a partially amputated finger 4 Adolescent boy with an oxygen saturation of 91%

3 Older adult male with a partially amputated finger

The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: 1 White blood cell (WBC) count of 8200/mm3 2 Bilateral 3+ pitting pedal edema 3 Oral temperature of 101.3º F 4 Pale skin and nail beds

3 Oral temperature of 101.3º F An elevated temperature of 101.3° F is most indicative of a systemic infection. A white blood cell (WBC) count of 8200/mm3 is within the WBC normal range of 5000-10,000/mm3. Pedal edema is generally not related to an infectious process. Pale skin and nail beds may be related to an infectious process but not necessarily.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? 1 Erosions 2 Macules 3 Papules 4 Vesicles

3 Papules Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation.

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to: 1 Promote gluconeogenesis. 2 Produce an anti-inflammatory effect. 3 Promote cell growth and bone union. 4 Decrease pain medication requirements

3 Promote cell growth and bone union. There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. High protein intake during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain.

Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client? 1 Encouraging frequent naps 2 Strengthening the concept of ageism 3 Reinforcing the client's strengths and promoting reminiscing 4 Teaching the client to increase calories and focusing on a high carbohydrate diet

3 Reinforcing the client's strengths and promoting reminiscing

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? 1 Increased physical activity 2 Absence of further outbursts 3 Relaxation of tensed muscles 4 Denial of the need for further discussion

3 Relaxation of tensed muscles Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.

When teaching about aging, the nurse explains that older adults usually have: 1 Inflexible attitudes 2 Periods of confusion 3 Slower reaction times 4 Some senile dementia

3 Slower reaction times

When nurses are conducting health assessment interviews with older clients, they should: 1 Leave a written questionnaire for clients to complete at their leisure 2 Ask family members rather than the client to supply the necessary information 3 Spend time in several short sessions to elicit more complete information from the clients 4 Keep referring to previous questions to ascertain that the information given by clients is correct

3 Spend time in several short sessions to elicit more complete information from the clients Spending time in several short sessions reduces client fatigue and compensates for a shortened attention span, which is common in the older adult. The questionnaire may never be completed if it is left for the client to complete at his or her leisure. Asking family members rather than the client to supply the necessary information is degrading to the client; the client should be asked initially and, if necessary, family can be asked to fill in details later. Constantly referring to previous questions may be overwhelming and create feelings of anger and resentment.

Which drug requires the nurse to monitor the client for signs of hyperkalemia? 1 Furosemide (Lasix) 2 Metolazone (Zaroxolyn) 3 Spironolactone (Aldactone) 4 Hydrochlorothiazide (HydroDIURIL

3 Spironolactone (Aldactone) Spironolactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect. Furosemide, metolazone, and hydrochlorothiazide generally cause hypokalemia.

To prevent footdrop in a client with a leg cast, the nurse should: 1 Encourage complete bed rest to promote healing of the foot. 2 Place the foot in traction. 3 Support the foot with 90 degrees of flexion. 4 Place an elastic stocking on the foot to provide support.

3 Support the foot with 90 degrees of flexion. To prevent footdrop (plantar flexion of the foot due to weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop . Applying an elastic stocking for support also will not prevent footdrop; a firmer support is required.

A nurse is caring for a client diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation 3 Surgical asepsis 4 Medical asepsis

3 Surgical asepsis

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids 2 Administer oxygen 3 Take the temperature 4 Collect a sputum specimen

3 Take the temperature Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.

A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action? 1 Notify the health care provider. 2 Report this to the nurse manager. 3 Tell the client that the cigarettes were found. 4 Discard the cigarettes without commenting to the client

3 Tell the client that the cigarettes were found.

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? 1 Maligning a person's character while threatening to do bodily harm. 2 A legal wrong committed by one person against property of another. 3 The application of force to another person without lawful justification. 4 Behaving in a way that a reasonable person with the same education would not.

3 The application of force to another person without lawful justification. Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons instead of property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1 diminished. 2 normal. 3 full. 4 bounding.

3 full. The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected/normal pulse, and a 4+ rating is a bounding pulse.

A client has been diagnosed as "brain dead". The nurse understands that this means that the client has: 1 no spontaneous reflexes. 2 shallow and slow breathing. 3 no cortical functioning with some reflex breathing. 4 deep tendon reflexes only and no independent breathing.

3 no cortical functioning with some reflex breathing. A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of "brain dead."

An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased.

4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased.

A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? 1 "Do you like living in this country?" 2 "When did you come to this country?" 3 "Is there a family member who can translate for you?" 4 "Which family member do you prefer to receive information?"

4 "Which family member do you prefer to receive information?"

A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as: 1 1+ 2 2+ 3 3+ 4 4+

4 4+ Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds then release to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2 + indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.

hen planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? 1 Kidney dysfunction 2 Cardiovascular diseases 3 Eye problems, such as glaucoma 4 Accidents, including their prevention

4 Accidents, including their prevention

Which of the following legal defenses is the most important for a nurse to develop? 1 Dedication 2 Certification 3 Assertiveness 4 Accountability

4 Accountability The concept of accountability is of high priority in nursing practice. As a licensed professional, the nurse is always accountable, which means liable and answerable for his or her actions.

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion? 1 Speaking aloud at weekly meetings 2 Promising to attend at least 12 meetings yearly 3 Maintaining controlled drinking after six months 4 Acknowledging an inability to control the problem

4 Acknowledging an inability to control the problem

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress. 2 A conscious defense against anxiety. 3 An intentional attempt to gain attention. 4 An unconscious means of reducing stress

4 An unconscious means of reducing stress

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing? 1 Vitamin A (Aquasol A) 2 Cyanocobalamin (Cobex) 3 Phytonadione (Mephyton) 4 Ascorbic acid (Ascorbicap)

4 Ascorbic acid (Ascorbicap) Vitamin C (ascorbic acid) plays a major role in wound healing. It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation.

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? 1 Teaching how to make a room allergy-free. 2 Referring to a support group for individuals with asthma. 3 Arranging with the college to ensure a speedy return to classes. 4 Evaluating whether the necessary lifestyle changes are understood

4 Evaluating whether the necessary lifestyle changes are understood

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? 1 Get a full report from the first nurse and adjust the plan accordingly. 2 Ask the health care provider for a report on the client's condition and plan appropriately. 3 Tell the client about the change in staff responsibilities and assess the client's reaction. 4 Assess the client's present status and include the client in a discussion of revisions to the plan of care

4 Assess the client's present status and include the client in a discussion of revisions to the plan of care

A nurse working in an emergency department is concerned about a recent increase in malpractice claims against nurses. What is the best way for the nurse to avoid being named in a lawsuit? 1 Carry malpractice insurance. 2 Write vague incident reports. 3 Transfer to another department. 4 Attend professional development programs.

4 Attend professional development programs. The best ways to prevent professional negligence (malpractice) are to attend continuing education programs and improve practice; additional education is advisable when one is working in specialty areas, such as emergency departments or intensive care areas.

The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, and specifically to avoid the intake of: 1 Milk 2 Cheese 3 Coffee 4 Cabbage

4 Cabbage Cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage. Milk, cheese, and coffee, in moderation, should not cause excessive gas problems. The client with a new colostomy should slowly introduce new foods into the diet to test toleration.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 4 Contracture

4 Contracture

What should the nurse do initially when obtaining consent for surgery? 1 Describe the risks involved in the surgery. 2 Explain that obtaining the signature is routine for any surgery. 3 Witness the client's signature, which the nurse's signature will document. 4 Determine whether the client's knowledge level is sufficient to give consent

4 Determine whether the client's knowledge level is sufficient to give consent

The unlicensed assistive person (UAP) assigned to the 7 am shift has not been coming to work until 8 am. Nursing care is delayed and assignments are started late. What is the most appropriate action by the charge nurse/team leader? 1 Discuss the issue with a friend from another unit 2 Remind the UAP of the expected start time 3 Report the problem to the Human Resources department 4 Document the information before discussing it with the UAP

4 Document the information before discussing it with the UAP

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1 Postural drainage 2 Cupping the chest 3 Nasotracheal suctioning 4 Frequent changes of position

4 Frequent changes of position

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? 1 Libel 2 Slander 3 Negligence 4 Invasion of privacy

4 Invasion of privacy

Which action by a home care nurse would be considered an act of euthanasia? 1 Implementing a "do not resuscitate" order in the home health setting. 2 Abiding by the decision of a living will signed by the client's family. 3 Encouraging a client to consult an attorney to document and assign a power of attorney. 4 Knowing that a dying client is overmedicating and not acting on this information.

4 Knowing that a dying client is overmedicating and not acting on this information. In this situation being aware that a client is overmedicating and taking no action can be considered an act of euthanasia on the part of the home care nurse. Implementing a "do not resuscitate" order, abiding by the decision of a living will signed by the client's family, and encouraging the client to consult an attorney are all appropriate actions for a home care nurse.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. The nurse recognizes that it is important to inform the client that he or she: 1 Is acting irresponsibly. 2 Is violating the hospital policy. 3 Must obtain a new healthcare provider for future medical needs. 4 Must accept full responsibility for possible undesirable outcomes

4 Must accept full responsibility for possible undesirable outcomes

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? 1 Private room 2 Semi-private room 3 Room with windows that can be opened 4 Negative airflow room

4 Negative airflow room Tuberculosis is an airborne contagious disease that is best contained in a negative airflow room. Negative airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial

4 Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? 1 Administer a mineral oil enema. 2 Offer one cup of fluid every hour. 3 Manually remove fecal impactions. 4 Offer a cup of prune juice.

4 Offer a cup of prune juice. Prune juice does not require a health practitioner order and helps to promote bowel movement because it contains sorbitol, which increases water retention in feces

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is the: 1 Suddenness of the change 2 Obviousness of the change 3 Extent of the body changes 4 Perception of the body changes

4 Perception of the body changes

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies an ocular problem common to persons at this client's developmental level, which is: 1 Tropia 2 Myopia 3 Hyperopia 4 Presbyopia

4 Presbyopia Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? 1 Alkalosis 2 Renal failure 3 Hypervolemia 4 Pulmonary edema

4 Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? 1 Tell the family to remove and dispose of the patch. 2 Leave the patch in place for the mortician to remove. 3 Have the family return the patch to the pharmacy for disposal. 4 Remove and dispose of the patch in an appropriate receptacle

4 Remove and dispose of the patch in an appropriate receptacle

The nurse prepares to give a prescribed capsule of hydroxyzine (Vistaril) to a client. The client begins to vomit so the nurse holds the oral medication. The nurse has not opened the medication package. Proper and safe disposal of the capsule of hydroxyzine requires the nurse to: 1 Drop the capsule into the sharps container 2 Crush the capsule and flush it into the sewer system 3 Place the capsule into a red biohazard bag and tie it shut 4 Return the capsule to the pharmacy

4 Return the capsule to the pharmacy Medication taken from a stock supply cannot be returned; it should be returned to the pharmacy for safe disposal.

The nurse recognizes that the mental process most sensitive to deterioration with aging is: 1 Judgment 2 Intelligence 3 Creative thinking 4 Short-term memory

4 Short-term memory

What should the nurse include in dietary teaching for a client with a colostomy? 1 Liquids should be limited to 1 L per day. 2 Non-digestible fiber and fruits should be eliminated. 3 A formed stool is an indicator of constipation. 4 The diet should be adjusted to include foods that result in manageable stools

4 The diet should be adjusted to include foods that result in manageable stools

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. The nurse is frustrated and tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted? 1 A system of rewards and punishment is being used to motivate the client. 2 Leaving the client alone allows time for the nurse to think of other strategies. 3 This behavior indicates the client's desire for solitude that the nurse is respecting. 4 This threat is considered assault, and the nurse should not have reacted in this manner.

4 This threat is considered assault, and the nurse should not have reacted in this manner. This response is a threat (assault) because the nurse is attempting to put pressure on the client to speak or be left alone. This is not a reward and punishment technique that is used in behavior modification therapy. Clients in emotional crisis should not be left alone.

Which nursing activities are examples of primary prevention? Select all that apply. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 Facilitating a program about smoking cessation

4 Assisting with immunization programs 5 Facilitating a program about smoking cessation Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention. Topics

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. A vesicle can be described as: 1 A lesion filled with purulent drainage. 2 An erosion into the dermis. 3 A solid mass of fibrous tissue. 4 A lesion filled with serous fluid.

A lesion filled with serous fluid. A vesicle is a small blisterlike elevation on the skin containing serous fluid. Vesicles are usually transparent. Common causes of vesicles include herpes, herpes zoster, and dermatitis associated with poison oak or ivy. A lesion filled with purulent drainage is known as a pustule; an erosion into the dermis is known as an excoriation or ulcer; and a solid mass of fibrous tissue is known as a papule.

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that pre-procedure prescriptions will include: 1 Providing instructions about restraints used during the procedure. 2 Administering a fleet enema 1 hour before the procedure. 3 Encouraging increased intake of clear fluids. 4 Administering morphine 30 minutes before the procedure.

Administering a fleet enema 1 hour before the procedure. To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A fleet or tap water enema should be used. The client will be kept NPO for at least 8 hours before the procedure. Morphine is not typically used as a pre-op medication before a sigmoidoscopy. Restraints are not typically used during the procedure.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin

Arterial blood gas All of these laboratory tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? 1 Prejudice 2 Stereotyping 3 Assimilation 4 Ethnocentrism

Assimilation Assimilation involves incorporating the behaviors of a dominant culture. Maintaining eye contact is characteristic of the American culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

The nurse is caring for a client that underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely caused from: 1 A normal response to the analgesic 2 Oral dryness caused by nasal packing 3 An adverse reaction to anesthesia 4 Bleeding posterior to the nasal packing

Bleeding posterior to the nasal packing Frequent swallowing may indicate bleeding in the posterior pharynx. Oral dryness causes thirst, not an increase in swallowing. Frequent swallowing is not a normal response to rhinoplasty or analgesics/anesthesia.

A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? 1 Cytomegalovirus 2 Histoplasmosis 3 Candida albicans 4 Human papillomavirus

Candida albicans White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeastlike fungal infection. This condition is also known as "thrush."

A nurse is reinforcing teaching to an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? (Select all that apply.) 1 "What is diabetes?" 2 "What will my friends think?" 3 "How do I give myself an injection?" 4 "Can you tell me how the glucose monitor works?" 5 "How do I get the insulin from the vial into the syringe?"

Correct 1 "What is diabetes?" Correct 4 "Can you tell me how the glucose monitor works?" Acquiring knowledge or understanding aids in developing concepts, rather than skills or attitudes, and is a basic learning task in the cognitive domain. Values and self-realization are in the affective domain. Skills acquisition is in the psychomotor domain.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? (Select all that apply.) 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness

Correct 4 Tachycardia Correct 5 Muscle weakness

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client's room. How should the nurse respond to the technician? 1 "I can't receive them right now. Please wait a few minutes or come back." 2 "Please leave the medications and sign-out sheet in a location where I can see them." 3 "Please bring them to me and I will be sure to put them away in a couple of minutes." 4 "I can't receive them right now. Please give them to the unlicensed assistive personnel (UAP)."

Correct1 "I can't receive them right now. Please wait a few minutes or come back." The transfer of controlled substances from one authorized person to another must occur according to protocol. In this situation the controlled substance must be returned to the pharmacy and delivered at a later time. The controlled substances cannot be left unattended. The nurse cannot delay the securing of controlled substances; if time is not available when the medications are delivered, they must be returned to the pharmacy. The UAP does not have the authority to receive controlled substances.

How can a nurse best evaluate the effectiveness of communication with a client? 1 Client feedback 2 Medical assessments 3 Health care team conferences 4 Client's physiologic responses

Correct1 Client feedback

A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? 1 Advising the client to join a support group immediately after discharge. 2 Assuring the family that staff members will take care of the client's needs. 3 Reminding the client to keep medical follow-up appointments after discharge. 4 Conducting a multidisciplinary staff conference early during the client's hospitalization.

Correct4 Conducting a multidisciplinary staff conference early during the client's hospitalization.

After several weeks of caring for clients who are in the terminal stage of illness, the nurse becomes aware of feeling depressed when coming to work. What should the nurse do? 1 Talk with other nurses on the unit. 2 Take several personal days off from work. 3 Limit emotional involvement with the clients. 4 Request a transfer to another area of the hospital.

Correct1 Talk with other nurses on the unit. Talking with nurses who cope with similar issues allows the nurse to share feelings and obtain constructive emotional support. Avoidance may provide an immediate solution, but it works only for a short time. The nurse will eventually have to work through feelings. Limiting emotional involvement with the clients avoids personal feelings about death and dying and is an unacceptable attitude when caring for dying clients. Emotional withdrawal may be perceived by the clients as rejection. Avoidance may provide an immediate solution, but it works only for a short time. The nurse will eventually have to work through feelings.

The nurse is preparing to reinforce teaching a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session? 1 Wait until a family member is also present. 2 Assess the client's barriers to learning self-injection techniques. t3 Begin with simple written instructions describing the technique. 4 Wait until the client has accepted the new diagnosis of Type 1 Diabetes Mellitus.

Correct2 Assess the client's barriers to learning self-injection

A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity? 1 Ambulation 2 Blowing the nose 3 Visiting with children 4 The semi-Fowler's position

Correct2 Blowing the nose Patients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the patient to avoid blowing their nose as this activity can increase the risk of bleeding. The following activities are not contraindicated with thrombocytopenia: ambulation, visiting with children, and semi-Fowler's position.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to: 1 Prevent a client from pulling out an IV when there is concern that the client cannot follow instructions or is confused. 2 Prevent an adult client from getting up at night when there is insufficient staffing on the unit. 3 Maintain immobilization of a client's leg to prevent dislodging a skin graft. 4 Keep an older adult client from falling out of bed following a surgical procedure.

Correct2 Prevent an adult client from getting up at night when there is insufficient staffing on the unit.

The nurse performs a respiratory assessment and auscultates breath sounds that are high-pitched, creaking and accentuated on expiration. Which term best describes the findings? 1 Rhonchi 2 Wheezes 3 Pleural friction rub 4 Bronchovesicular

Correct2 Wheezes Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and COPD. Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.) 1 Difficulty in swallowing 2 Diminished sensation of pain 3 Heightened response to stimuli 4 Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat

Correct2 Diminished sensation of pain Correct4 Impaired hearing of high-frequency sounds

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the most appropriate initial nursing action? 1 Use techniques to distract the client. 2 Include the client in decision making. 3 Offer to spend more time with the client. 4 Help the client to problem-solve personal issues

Correct3 Offer to spend more time with the client. Because of the profound effect of paralysis on body image, the nurse should foster an environment that permits exploration of feelings without judgment, punishment, or rejection. Attempts to distract the client may be interpreted as denial of the client's feelings and will not resolve the underlying problem. Including the client in decision making and helping the client to problem-solve personal issues are an important part of nursing care, but they are not related to the client's feelings.

What should a nurse recommend to help a client best during the period immediately after a spouse's death? 1 Crisis counseling 2 Family counseling 3 Marital counseling 4 Bereavement counseling

Correct4 Bereavement counseling Bereavement counseling involves being a part of a group of people who also have sustained a loss; members provide support to each other. Individual counseling will not provide the support that a group provides; group counseling may last longer than crisis intervention. The information provided did not indicate other family members. Marital counseling involves both a husband and a wife.

When being interviewed for a position as a licensed practical nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1 Negligence 2 Malpractice 3 Breach of duty 4 False imprisonment

Correct4 False imprisonment False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development? 1 It provides rewards and punishment. 2 The child's development is supported. 3 It reflects the mores of a larger society. 4 It is where child's identity and roles are learned

Correct4 It is where child's identity and roles are learned Socialization, values, and role definition are learned within the family and help develop a sense of self. Once established in the family, the child can move more easily into society.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? 1 Acknowledge the client's crying. 2 Encourage unrestricted family visits. 3 Explain details of the care being given. 4 Stay nearby without initiating conversation

Correct4 Stay nearby without initiating conversation

A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider? 1 Personality traits 2 Educational level 3 Cultural background 4 Past experiences with death

Cultural background In the initial stage of grief the degree of anguish experienced is influenced by cultural background. Although personality traits factor into the grief process, they are not as important as culture. Educational level is not related directly to a grief response. While past experience is important, it is not as significant as culture.

Considering Erikson's developmental theories, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with: 1 Mastering his environment 2 Identifying with the male role 3 Developing meaningful relationships 4 Differentiating himself from the environment

Developing meaningful relationships Developing meaningful relationships is the young-adult task associated with intimacy versus isolation. Mastering his environment is a toddler's task associated with autonomy versus shame and doubt. Identifying with the male role is a preschool-age child's task associated with initiative versus guilt. Differentiating himself from the environment is a toddler's task associated with autonomy versus shame and doubt.

A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond? 1.Allow the visitor to review the record; sponsors have access to privileged information 2.Ask the primary health care provider about granting permission to the sponsor 3.Do not allow the sponsor to review the record 4.Allow the visitor to review the record; clients with alcoholism need reassurance from sponsors

Do not allow the sponsor to review the record

A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first? 1 Page the on-call health care provider and continue to monitor the blood pressure. 2 Administer ibuprofen and have the client rest quietly for 20 minutes. 3 Elevate the head of the bed, provide reassurance, and reassess the blood pressure. 4 Place the client in the supine position, administer oxygen, and notify the health care provider.

Elevate the head of the bed, provide reassurance, and reassess the blood pressure. Blood pressure increases with pain and stress; reevaluation is critical before determining if the health care provider should be notified. Assessment should be completed before notifying the health care provider. Prescribing medications is a dependent function of the nurse, and medication should not be administered until the cause of the headache is determined. Oxygen is not indicated. The head of the bed should be elevated. The health care provider should be notified if a second blood pressure reading remains elevated.

When caring for a client with pneumonia, which nursing intervention is the highest priority? 1 Increase fluid intake. 2 Employ breathing exercises and controlled coughing. 3 Ambulate as much as possible. 4 Maintain an NPO status.

Employ breathing exercises and controlled coughing. For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered his or her regular diet as tolerated.

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1 Evaluation 2 Data Collection 3 Nursing interventions 4 Proposed nursing care

Evaluation

A client expresses concern about the surgical consent that the client signed. How should the nurse respond? 1 Share the client's concern with the family 2 Inform the health care provider of the client's concern 3 Reassure the client that the surgery will be successful 4 Cancel the surgery until the client feels more comfortable with the decision

Inform the health care provider of the client's concern

A nurse receives a shift report on four adult clients that are between the ages of 25-55. Which client should the nurse assess first? 1 Male client with a hemoglobin of 15.9 2 Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5 3 Female client taking daily calcium supplements with a serum calcium level of 9.4 4 Male client with a blood urea nitrogen (BUN) of 20 and a creatinine of 1.1

Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5 The client on warfarin (Coumadin) with an INR of 7.5 should be assessed first by the nurse, because this is an elevated result. Normal is considered between 2 and 3. This result is not therapeutic, and the nurse should assess for bleeding and hemodynamic stability. The nurse should report the result to the primary healthcare provider and implement bleeding precautions. The other results are within normal ranges: hemoglobin for a male is 14-18 g/dL; serum calcium is 9.0-10.5 mg/dL; BUN is 5-20 mg/dL and creatinine is 0.7-1.5 mg/dL.

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is: "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1 Focusing 2 Restating 3 Exploring 4 Accepting

Focusing

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every four hours. Which diet should the nurse expect the health care provider to prescribe to best meet this client's immediate nutritional needs? 1. Low in fat and vitamin D 2. High in calories and fiber 3. Low in residue and bland 4. High in protein and vitamin C

High in protein and vitamin C

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. 2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. 3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities following hospitalization do not require rehabilitation.

Immediate or potential rehabilitation needs are exhibited by clients with health problems. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of: 1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Generativity versus stagnation

Integrity versus despair According to Erikson, poor self-concept and feelings of despair are conflicts manifested in those who are older than 65 years of age. The initiative versus guilt conflict is manifested in early childhood between 3 and 6 years of age. The industry versus inferiority conflict is manifested during the ages from 6 to 11 years. The generatively versus stagnation conflict is manifested during middle adulthood, 45 to 65 years of age.

The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are: 1 Ready for discharge and therefore in need of preparation 2 At the peak of mental anguish and therefore open to change 3 Less angry and therefore more compliant and more receptive 4 Less anxious and more aware of reality and therefore ready to learn

Less anxious and more aware of reality and therefore ready to learn

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: 1. Picks up the walker and carries it for short distances. 2. Uses the walker only when someone else is present. 3. Moves the walker no more than 12 inches in front of the client during use. 4. States that a walker will be purchased on the way home from the hospital

Moves the walker no more than 12 inches in front of the client during use

A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurological impairment. Legally, who is responsible for the child's injury? 1 Health care provider, because this decision took precedence over the nurse's concern 2 Health care provider, because of total responsibility for the child's health and treatment regimen 3 Nurse, because failure to further question the health care provider about the child's status placed the child at risk 4 Neither, because high fevers are common in children and the health care provider had little cause for concern

Nurse, because failure to further question the health care provider about the child's status placed the child at risk It is the nurse's responsibility to foresee potential harm and prevent risks by acting as a client advocate. This is not acceptable as a rationale for inaction. The nurse and health care provider share interdependent roles in the assessment and care of clients. High temperatures are common in children but are nonetheless a valid cause for concern.

Which client assessment finding should the nurse document as subjective data? 1 B/P 120/82 2 Pain rating of five (5) 3 Potassium 4.0 mEq 4 Pulse oximetry reading of 96%

Pain rating of five (5)

A 90-year-old female resident of a nursing home falls and fractures the proximal end of her right femur. The surgeon plans to reduce the fracture with an internal fixation device. The general fact about the older adult that the nurse should consider when caring for this client is that: 1 Aging causes a lower pain threshold 2 Physiological coping defenses are reduced 3 Most confused states result from dementia 4 Older adults psychologically tolerate changes well

Physiological coping defenses are reduced

A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? 1 Make a new prayer cloth. 2 Discard the soiled prayer cloth. 3 Pin the prayer cloth to the clean gown. 4 Wash the prayer cloth with a detergent.

Pin the prayer cloth to the clean gown The prayer cloth has religious significance for the client and should be preserved as is. Making a new prayer cloth disregards what the prayer cloth means to the client. The prayer cloth is the property of the client and should not be discarded. Washing the prayer cloth with a detergent disregards what the prayer cloth means to the client; this never should be done without the client's permission.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 Raised to 45 degrees 4 Raised to 10 degrees

Raised to 45 degrees

Which nursing action is confidential and protected from legal action? 1 Providing health teaching regarding family planning. 2 Offering first aid at the scene of an automobile collision. 3 Reporting incidents of suspected child abuse to the appropriate authorities. 4 Administering resuscitative measures to an unconscious child pulled from a swimming pool

Reporting incidents of suspected child abuse to the appropriate authorities

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1 Maintain the head of the bed at 35 degrees or less. 2 With the help of another staff member, use a drawsheet when lifting the client in bed. 3 Reposition the client at least every 2 hours and support the client with pillows. 4 At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

With the help of another staff member, use a drawsheet when lifting the client in bed.

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted? 1.These actions can be construed as assault and battery. 2.The problem was resolved with forethought and accountability. 3.Skin must be protected, and the actions taken were by a reasonably prudent nurse. 4.The nurse had tried to reason with the toddler and expected understanding and cooperation

These actions can be construed as assault and battery Assault is a threat or an attempt to do violence to another, and battery means touching an individual in an offensive manner or actually injuring another person.

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection: 1 To the client from outside sources. 2 From the client to others. 3 From the client by using special techniques to destroy infectious fluids and secretions. 4 To the client by using special sterilization techniques for linens and personal items.

To the client from outside sources