Exam 1

A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago. The nurse's best response to the mother is: "I will let the doctor know, and he will talk with you about possible causes of your infant's weight loss." "A weight loss of a few ounces is common among newborns, especially for breast- feeding mothers." "I can tell you are a first-time mother. Don't worry; we will find out why she is losing weight." "Maybe she isn't getting enough milk. How often are you breastfeeding her?"

"A weight loss of a few ounces is common among newborns, especially for breast- feeding mothers."

The nurse instructs a group of pregnant patients about Lamaze techniques. During class, the nurse hears one participant tell another participant, "Taking medication during pregnancy is very risky, so you should stop taking the medication your health care provider prescribed." Which response by the nurse is best? "You are correct that taking any medication any time during pregnancy is dangerous." "Depending on the medication and the trimester of pregnancy, appropriate choices can be made." "Taking medication will not affect your fetus because the amniotic fluid provides a protective barrier." "Taking oral medications is acceptable because oral medications are metabolized in the mother's stomach, not the uterus."

"Depending on the medication and the trimester of pregnancy, appropriate choices can be made."

A patient in the early stages of pregnancy is suffering from "morning sickness". Which statement by the patient requires you to further educate the patient about this condition? "I have been addicted to Mexican food and fried pickles lately." "I eat frequently throughout the day, and they are small amounts". "I have my saltines at my bedside to munch on before I get up". "I know this morning sickness will pass and I should feel better in the 2nd trimester".

"I have been addicted to Mexican food and fried pickles lately."

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment into the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states: "I will cleanse the neonate's eyes before instilling ointment." "I will flush the eyes after instilling the ointment." "I will instill the eye ointment into each of the neonate's conjunctival sacs within one hour after birth." "Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur."

"I will flush the eyes after instilling the ointment."

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply: 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test

A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully understand the risks and benefits associated with the procedure. Which of the following describe the nurse's role in obtaining informed consent? Select all that apply. 1. Explain the risks and benefits associated with the procedure 2. Describe alternatives to the procedure 3. Witness the client's signature on consent form

1. Explain the risks and benefits associated with the procedure 3. Witness the client's signature on consent form One of the nurse's role in the informed consent process is to witness the signature on the consent form One of the nurse's role in the informed consent process is to advocate for the client by ensuing she has been provided the necessary information to make an informed decision

A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take? 1. Immobilize the affected limb with a splint and ask him not to move 2. Make a thorough assessment of the circumstances surrounding the accident 3. Put him in semi-Fowler's position for comfort 4. Check the pedal pulse and blanching sign in both legs

1. Immobilize the affected limb with a splint and ask him not to move The "FIRST action" element tells us that this is indeed a priority question. We will use the nursing process to determine the best FIRST action, however the context of the question reveals that the nurse has determine that the boy has a possible fracture. This implies that the nurse has completed the assessment step. It is now time to implement. Eliminate the answer choices that are assessments. This leaves us with 2 implementation choices: immobilizing the limb or semi-fowler's. Semi-fowler's is not indicated for a suspected fracture (it would be indicated for someone in respiratory distress), thus immobilizing the limb is the most appropriate FIRST action within the context the question already provides.

The nurse has dealt with an emergent situation and is attempting to catch up on scheduled tasks. The nurse plans to delegate some tasks to an unlicensed assistive personnel. Which of the following tasks are within the UAP's scope of practice and appropriate for the nurse to delegate? (Select all that apply) 1. Obtain vital signs and document appropriately in the client's medical record. 2. Feed the client and assess the risk for aspiration 3. Assist the client with bathing and grooming 4. Perform indwelling urinary catheter care and appropriately document the client's I&O 5. Perform a sterile dressing change on a CVC 6. Ensure the client takes all medication left at the bedside by the nurse

1. Obtain vital signs and document appropriately in the client's medical record. 3. Assist the client with bathing and grooming 4. Perform indwelling urinary catheter care and appropriately document the client's I&O

The nurse on the medical-surgical unit talks with a client about an advance directive. Which response by the client indicates the client understands the information? 1. When I complete my advance directive, I need to be sure there is a copy available to my health care provider and health care proxy. 2. The person I select for my durable power of attorney cannot have any legal or financial attachments to me. 3. The decisions of my advance directives can not be changed as long as I am still able to communicate my wishes. 4. After my death, the durable power of attorney can determine my funeral arrangements and handle my finances.

1. When I complete my advance directive, I need to be sure there is a copy available to my health care provider and health care proxy. Making the advance directive known to the HCP and family member, makes it accessible when it is needed, which makes the first choice correct. The person usually selected as a POA is a family member or spouse, so answer 2 would be incorrect. Answer 3 is incorrect because advance directives CAN be changed as long as a person can communicate their wishes. And a POA is used to make decisions about a person's care while they are still living, and is terminated after the person dies.

Which action(s) violate the HIPAA? select all that apply 1.Discussing the comatose patient's condition with his father in -law. 2.Discussing the outcome of a patient's test with another nurse from the unit while in a crowded elevator. 3.Relaying information about the patient's concerns to the nurse who will care for him on the next shift. 4.Relaying a complaint about the quality of nursing care by the patient's wife to the charge nurse. 5.Updating your social media site about a difficult clinical day, including hospital and patient's diagnosis, but NOT the patient's name.

1.Discussing the comatose patient's condition with his father in -law. 2.Discussing the outcome of a patient's test with another nurse from the unit while in a crowded elevator. 5.Updating your social media site about a difficult clinical day, including hospital and patient's diagnosis, but NOT the patient's name. Violation of patient's privacy by discussing health records with people not directly involved in their care either professionally or legally or in a situation that others could hear the details of a patient's health records.

A patient with postpartum depression is scheduled for discharge today. Which of the following statements by the patient would indicate the postpartum depression has RESOLVED? 1) I feel great, so much better! 2) That scary fog that was clouding my head has disappeared. I feel much more supported and able to care for my baby. 3) I feel a little stressed, but I might be able to care for my baby safely. 4) I've missed my baby so much.

2) That scary fog that was clouding my head has disappeared. I feel much more supported and able to care for my baby.

The nurse provides care for pediatric clients diagnosed with AIDS. All of the clients are school-aged. How does the nurse coordinate the necessary isolation precautions? 1. Ensure that everyone on the unit wears gloves at all times. 2. Remind the staff that standard precautions are needed. 3. Post a sign on the door of all clients with AIDS or other infectious disorders. 4. Teach the children to warn others that they have AIDS.

2. Remind the staff that standard precautions are needed.

The nurse provides care fro an adolescent client with suspected gonorrhea. The client reports being sexually abused by a parent for the past 5 years/ Which action does the nurse perform first? 1. attmpt to determine what type of incident preceded the acts of sexual abuse. 2. contact the child protection agencey and report the client's statement immediately. 3. assess whether the client understands the meaning of sexual intercourse. 4. tell the client that reporting this information is a step toward getting help.

2. contact the child protection agency and report the client's statement immediately.

Which client situation demonstrates a need for further teaching/intervention on appropriate informed consent? 1. the patient states, "I will be undergoing a complete mastectomy today at 1200. My doctor came in to talk to us yesterday." 2. the parents of a 4 year old child explain to the nurse that they don't understand what the risks are for their child's appendectomy surgery tomorrow. 3. The patient shares, "I'm ready for my procedure in a week. It's been a long time coming before getting my new lungs" 4. A 15 year old explains that they will have to wait 2 weeks after their surgery before they can resume their afterschool sports club.

2. the parents of a 4 year old child explain to the nurse that they don't understand what the risks are for their child's appendectomy surgery tomorrow. Answer 2 is the correct answer. #2 shows that the parents of the child do not have appropriate comprehension of the surgery. The checklist to ensure informed consent involves disclosure, comprehension, competence and voluntariness. If the parents are unaware of the risks of an appendectomy they have inappropriately consented to a procedure for their child. The risks of the surgery could have an impact on their decision.

The nurse delegates care to be provided during the shift to the team members. Which duty can the nurse safely and appropriately delegate to the LPN/LVN? 1.Perform a venipuncture and start an IV drip. 2.Perform a dressing change with sterile procedure. 3.Hang a unit of packed red blood cells. 4.Perform a urethral catheterization on a post-TURP client.

2.Perform a dressing change with sterile procedure. The correct answer is "perform a dressing change with sterile procedure." This is a simpler intervention that is within the LPN's scope of practice in all states. LPN's may NOT start an initial IV infusion in many states. LPN's cannot administer blood. While LPN's can catheterize, they cannot be assigned a fresh post-operative client as he is considered to be unstable.

You are providing care to a patient withC.Diff. After removing the appropriate PPE, you would perform hand hygiene by: 1.using hand sanitizer 2.using soap and water 3.using soap and water only if hands are soiled but can use hand sanitizer 4.using either hand sanitizer or soap and water

2.using soap and water

The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin-resistant Staphyloccus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse would assemble which necessary protective items before entering the client's room? 1. Gloves and gown 2. Gloves and face shield 3. Gloves, gown and face shield 4. Gloves, gown, and shoe protectors

3. Gloves, gown and face shield

In which client situation would the advance directive be consulted and used in decision making? 1. The client diagnosed with Guillain-Barré who is on a ventilator. 2. The client with a C6 spinal cord injury in the rehabilitation unit. 3. The client in end-stage renal disease who is in a comatose state. 4. The client diagnosed with cancer who has Down syndrome.

3. The client in end-stage renal disease who is in a comatose state. The client must have lost decision making capacity as a result of a condition which is not reversible or must be in a condition specified under state law, such as a terminal, persistent vegetative state; an irreversible coma; or as specified in the AD.

A nurse admits a client who is experiencing nausea and vomiting to the emergency department. The client is alone. The nurse completes an assessment and prepares to leave the room. Which is the safest instruction for the client? 1. "If you need to vomit, here is a basin for you. I don't want you to get up on your own." 2. "I will be in the room next door. I'll check back in about 10 minutes." 3. "I will go update the doctor about you. Do you need anything before I go?" 4. "Here is the nurse call light. Press this button if you need me."

4. "Here is the nurse call light. Press this button if you need me."

The nurse evaluates clients in the gastrointestinal clinic. Which client does the nurse see first? 1. A middle-age client diagnosed with irritable bowel syndrome reports cramping and loose stools. 2. A young adult client reports not have a bowel movement in 2 days. 3. A school-age client diagnosed with gastroenteritis who had five diarrheal stools in the last 3 days. 4. A newborn client experiencing projectile vomiting and irritability.

4. A newborn client experiencing projectile vomiting and irritability. The last option is correct because the projectile vomiting in a newborn can indicate pyloric stenosis and this puts them at risk for fluid/electrolyte imbalance. They all seemed to be on the same boat of importance but because of the keyword projectile vomiting, the priorities have changed.

A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? 1. Administer pain meds 2. Administer IV fluids 3. Administer dopamine 4. Administer O2 via NC

4. Administer O2 via NC Correct answer is administer O2 via NC. The rationale per NursesLabs is that oxygenation is most important because we must think about ABCs, so O2 would be given highest priority. "Administering IV fluids belong in Maslow's physical and biological needs, but still after airway." Dopamine can also be used to treat low BP, especially in cases of shock, low HR and cardiac arrest; it would be continuous IV drip. However, the priority here was oxygenation.

A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client's permission

4. Observing care provided to the client without the client's permission Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. The key word in option 4 is "without the client's permission". Option 1 is an example of battery. Option 2 threatening to give a client a medication constitutes assault. Option 3 telling the client that the client cannot leave the hospital constitutes false imprisonment.

Which of these clients is at greatest risk for falls? A 32 year old female client in a client room that has low glare floors An 87 year old female client in a client room that has low glare floors A 27 year old sedated male client A 37 year old male client with impaired renal perfusion

A 27 year old sedated male client

The patient with a cervical SCI has been placed in fixed skeletal traction with halo fixation device. When caring for this patient the nurse may delegate which action (s) to the LPN/LVN? Select all that apply. A) Check the patient's skin for pressure from the device B) Assess the patient's neurologic status for changes C) Observe the halo insertion sited for signs of infection D) Clean the halo insertion sites with hydrogen peroxide

A) Check the patient's skin for pressure from the device C) Observe the halo insertion sited for signs of infection D) Clean the halo insertion sites with hydrogen peroxide Checking for signs of infection of pressure and observing for signs of infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic assessments require additional education and skill appropriate to the professional RN.

After a conference with the family, a patient's care provider writes a Do-Not-Resuscitate (DNR) order. What does the nurse understand when planning care for this patient? A) Nursing care will continue with the treatment orders in place B) DNR orders from a previous hospitalization will be valid and legal C) The patient and family may no longer make medical decisions D) Death will take place within the next 72 hours, so the family should prepare.

A) Nursing care will continue with the treatment orders in place A DNR order only controls CPR and similar life-saving treatments. All other care and treatment should continue as ordered. Competent patients can still decide about their own care, including whether to rescind the DNR order. A new DNR order is written with each hospitalization. It does not carry over to the next hospital.

As the RN, which tasks below should you NOT DELEGATE to the LPN: SATA A) performing an assessment on a new admission B) Collect urine sample from an indwelling catheter C) Check patients' blood glucose before breakfast D)Educate the patient about side effects associated with the medication E) Start a blood transfusion F) Provide wound care for a stage 2 pressure injury

A) performing an assessment on a new admission D)Educate the patient about side effects associated with the medication E) Start a blood transfusion These are the correct answers because these are all responsibilities of the RN. The RN handles education, assessment, and teaching (EAT). As well they are responsible for medication and blood administration.

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. A brief neurologic assessment B. Client's allergy history C. Initiation of pulse oximetry D. Complete set of vital signs

A. A brief neurologic assessment

Which stage of development is most unstable and challenging regarding the development of personal identity? A. Adolescence B. Toddlerhood C. Middle Childhood D. Young adulthood

A. Adolescence

A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to A. Allow the newborn to signal his/her needs B. Anticipate all needs of the newborn C. Avoid the newborn during the first 10 minutes of crying D. Allow the newborn to cry once, and then settle down before attending to him/her

A. Allow the newborn to signal his/her needs

Nurses agree to be advocates for their patients. The practice of advocacy calls for the nurse to which of the following? A. Assess the patient's perspective and explain it when necessary. B. Apply the law to the patient's clinical condition. C. Seek out the nursing supervisor to resolve conflict. D. Document all clinical changes in the medical record every 2 hours.

A. Assess the patient's perspective and explain it when necessary.

Nurses agree to be advocates for their patients. The practice of advocacy calls for the nurse to which of the following? A. Assess the patient's perspective and explain it when necessary. B. Apply the law to the patient's clinical condition. C. Seek out the nursing supervisor to resolve conflict. D. Document all clinical changes in the medical record every 2 hours.

A. Assess the patient's perspective and explain it when necessary. The definition of patient advocacy is to ensure your patient understands each aspect and step of their care and consents to it which is what A is saying.

Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply. A. Assist the patient to reposition every 2 hours. B. Reapply pneumatic compression boots. C. Remind the patient to perform active ROM. D. Check extremities for redness and edema.

A. Assist the patient to reposition every 2 hours. B. Reapply pneumatic compression boots. C. Remind the patient to perform active ROM. The nursing assstant can do the tasks described in A, B, and C as they are within their scope of practice. The wording in C may seem tricky but the nursing assistant is reminding the patient. The nurse would still be the one to do the initial teaching of performing active ROM. D is incorrect because it is an assessment and that should be completed by the nurse.

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant? A. Assisting the patient to sit up on the side of the bed. B. Instructing the patient to cough effectively. C. Teaching the patient to use incentive spirometry. D. Auscultation of breath sounds every 4 hours.

A. Assisting the patient to sit up on the side of the bed. Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. More examples of tasks that can be delegated to nonprofessional, unlicensed assistive nursing personnel and under the direct supervision of the nurse include range of motion, feeding, and ambulation. Teaching, evaluating, and assessing do not fall under their scope of practice.

Which intervention for airway management in a patient with chronic obstructive pulmonary disease (COPD) should you delegate to a nursing assistant? A. Assisting the patient to sit up on the side of the bed. B. Instructing the patient to cough effectively. C. Teaching the patient to use incentive spirometry. D. Auscultation of breath sounds every 4 hours.

A. Assisting the patient to sit up on the side of the bed. Rationale: Remembering the information from our learning module, we know that the nurse cannot delegate any task that involves the nursing process, which includes the tasks incorporated in the acronym TEAACUP: teaching, evaluation, assessment, advanced interventions, collaboration, unstable patients, or planning. This eliminates the interventions that require instructing, teaching, and auscultating. Assisting the patient to sit up on the side of the bed is a task that can be safely and legally performed by the nursing assistant as positioning and assisting with ADL's are within their scope of practice.

A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? A. Endometritis B. Endometriosis C. Salpingitis D. Pelvic thrombophlebitis

A. Endometritis

Select All That Apply: Alternative Preventative Measures that can be used with patients in lieu of restraints to prevent a fall are: A. Increased frequency of monitoring B. Bed Alarm C. Sitter D. Vest on patient E. Reorienting the patient

A. Increased frequency of monitoring B. Bed Alarm C. Sitter E. Reorienting the patient

A patient is admitted to the unit with an order for seizure precautions. Which action is most appropriate? A. Maintain the client's bed in the lowest position. B. Ensure that soft limb restraints are applied to upper extremities. C. Move the client to a room closer to the nurses' station. D. Keep the cilent NPO

A. Maintain the client's bed in the lowest position.

Which one of the following statement by the parents of the child indicates that further teaching by the nurse is required? A. Now the my child is 2 years old, I can let her sit on the front seat of the car with me. B. I make sure that my child wears a helmet when he rides his bicycle. C. I have spoken to my child about safe sex practices. D. My child is taking swimming classes at the community center.

A. Now the my child is 2 years old, I can let her sit on the front seat of the car with me.

Which of the following patient's require additional resources to ensure informed consent is properly given? A. Patient with a subset dialect of major language. B. Patient who is having difficulty coping with the medical prognosis. C. Patient who has fully accepted the risks of the procedure and possible outcomes. D. Patient who has a set up a power of attorney and advanced directive in preparation for surgery. E. Patient who is an adolescent, but the physician has explained the procedure to the parents and the medical necessity.

A. Patient with a subset dialect of major language. The answers are Patient with a subset dialect of a major language. Parts of informed consent are disclosure, comprehension, competence and voluntariness. Even though the dialect may share enough words with the major language, not all words are 1 to 1 translation and it would be best to obtain a translator in the patient's dialect in order best to communicate the information to the patient so they fully comprehend the situation/procedure needed. Without comprehension, it would be difficult to fulfill other requirements of informed consent such as disclosure, competence and voluntariness.

As the registered nurse, which tasks below should you NOT delegate to the LPN? (SATA) A. Performing an assessment on a new admission B. Collecting a urine sample from an indwelling Foley catheter C. Developing a plan of care for a patient who is admitted with Guillain-Barré Syndrome D. Educating a patient about how to monitor for side effects associated with Warfarin E. Auscultating lung and bowel sounds F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain H. Providing wound care to a stage 3 pressure injury

A. Performing an assessment on a new admission C. Developing a plan of care for a patient who is admitted with Guillain-Barré Syndrome D. Educating a patient about how to monitor for side effects associated with Warfarin F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain The nurse should not delegate any assessments, development of plan of care, initial education, IV medications, or complex procedures such as blood transfusions. Focused assessments are in the LPN's scope of practice which makes auscultating lung and bowel sounds acceptable to delegate, but it is up to the RN to perform a comprehensive assessment and follow up on any findings the LPN reports from their focused assessment. The LPN can also perform predictable standard procedures on stable patients which include wound care, Foley catheter insertion, obtaining an EKG, and obtaining a blood glucose level.

A 15-month-old child weighs 26 lbs. and is 35 inches. What type of car seat below is considered the SAFEST for this child to use while riding in a motor vehicle? A. Rear-facing B. Forward-facing C. Booster seat D. Seat belt

A. Rear-facing

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? A. The diet should include additional fluids. B. Prenatal vitamins should be discontinued. C. Soap should be used to cleanse the breasts. D. Birth control measures are unnecessary while breast-feeding.

A. The diet should include additional fluids.

Select below the positive signs of pregnancy: A. Ultrasound detecting fetus B. Visible movement of baby seen by the examiner C. The delivery of the baby D. Doppler detects fetal heart tones E. Fetal movement felt by examiner F. Braxton Hicks Contractions

A. Ultrasound detecting fetus B. Visible movement of baby seen by the examiner C. The delivery of the baby D. Doppler detects fetal heart tones E. Fetal movement felt by examiner

A patient with a pulmonary embolism is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. A. Use a lift sheet when moving and positioning the patient in bed. B. Use an electric razor when shaving the patient each day. C. Use a soft-bristled toothbrush or tooth sponge for oral care. D. Use a rectal thermometer to obtain a more accurate body temperature. E. Be sure the patient's footwear has a firm sole when the patient ambulates.

A. Use a lift sheet when moving and positioning the patient in bed. B. Use an electric razor when shaving the patient each day. C. Use a soft-bristled toothbrush or tooth sponge for oral care. E. Be sure the patient's footwear has a firm sole when the patient ambulates. All of the other instructions are appropriate to the care of a patient receiving anticoagulants and they are intervention a CNA is able to do. Risk for bleeding may arise in any condition that disturbs the "close circuit" integrity of the circulatory system. Bleeding is the primary complication of anticoagulant therapy and is a risk of all anticoagulants even when maintained within the usual therapeutic ranges.

The nurse witnessed a patient trip and fall on the hose of the SCD. They decide to fill out an incident report sheet on the computer. What should be included in the report? select all that apply A. date and time B. witnesses C. whos fault it was D. description of the incident E. what was for lunch

A. date and time B. witnesses D. description of the incident

A nurse is getting ready to discharge a patient and is going to provide teaching on some medication the patient will be taking at home. However the nurse receives a new admission and the patient is requesting to see the nurse immediately and has become aggressive. The nurse decides to delegate some of their tasks to the UAP. Which tasks can the UAP do for the discharged patient? select all that apply A. help the patient gather their belongings B. provide medication teaching C. discuss the plan of care D. help patient change into their personal clothes

A. help the patient gather their belongings D. help patient change into their personal clothes UAP are not allowed to provide teaching or perform any complex tasks such as discussing the plan of care. These actions are only to be performed by the nurse. LPN can reinforce teaching once the nurse has already provided the initial teaching. Remember the TEAACUP acronym when deciding what actions can be delegated by the nurse

What stage of development is most unstable and challenging regarding the development of personal identity? Adolescent Toddlerhood Young adult Older adult

Adolescent

An adolescent Hispanic client is diagnosed with generalized anxiety disorder (GAD). The parent mentions the client has asked a priest to help protect against "mal ojo" or the evil eye. Which action is appropriate for the nurse to take in response to the parent's statement? (SATA) Ask the parents what time the priest is coming over and if any special preparation Explain to the client that belief in "mal ojo" is superstitious. Involve the priest in consultation with the parent, the primary care provider, and the nurse Avoid talking to the parent about the client inviting the priest Tell the parent that contacting a priest for a diagnosis of GAD in unnecessary Explain to the parent that the treatment for GAD is based on western medicine.

Ask the parents what time the priest is coming over and if any special preparation Involve the priest in consultation with the parent, the primary care provider, and the nurse

A clinic nurse assesses the communication patterns of a five (5)-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement expected if the infant: A - Uses simple words such as "mama" B - Uses monosyllabic babbling C - Links syllables together D - Coos when comforted.

B - Uses monosyllabic babbling

The nurse is caring for a client with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of the following nursing actions can a nurse assign to an LPN? A) Assessment for further skin breakdown B) Collect wound cultures during dressing changes C) Create methods to improve the client's oral protein intake D) Educate the client about home care of the leg ulcer

B) Collect wound cultures during dressing changes The LPNs scope of practice includes wound cultures and dressing changes. Additional routine procedures that the LPN can do includes catheter insertion, checking blood glucose, obtaining EKGs, and ostomy care. Option A is not correct because an LPN cannot perform an initial and complete physical assessment. Option C is not correct because the LPN does not develop nursing diagnoses or evaluate the care plan. Option D is not correct because education is a complex action that should be carried out by the RN.

The nurse delegates care to be provided during the shift to the team members. Which duty can the nurse safely and appropriately delegate to the licensed practical nurse/ vocational nurse (LPN/LVN)? A) Perform a venipuncture and start an intravenous (IV) drip B) Perform a dressing change with sterile technique C) Hang a unit of packed red blood cells (PRBCs) D) Perform a urethral catheterization on a post-TURP patient.

B) Perform a dressing change with sterile technique It is not hanging a unit of PRBCs because LPN/LVP are not allowed to hang blood because it is out of their scope of practice. Although in some states a LPN/LVP can be the second licensed person checking the blood identification, and they can also take the vital signs throughout the transfusion. It is not a urethral catheterization on a post-TURP patient because although they can perform urethral catheterization the patient is post-op so will need an initial assessment for bleeding or clotting from an RN first. It is not starting IVs or initiating IV infusions because in many states this is out of their scope of practice. The correct answer is performing a dressing change with sterile technique because sterile dressing change is within the LPN/LVNs scope of practice in all states!

You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant A) Assessing the patient's respiratory status every 4 hours B) Taking vital signs and pulse oximetry readings every 4 hours C) Checking the ventilator settings to make sure they are as prescribed D) Observing whether the patient's tube needs suctioning every 2 hours

B) Taking vital signs and pulse oximetry readings every 4 hours Option A- This is incorrect because this task should include not only counting respirations but also listening the breath sounds and noting the work of the breathing. All these tasks are at the RN level. Option B- This is the correct answer because obtaining vitals which includes pulse oximetry readings are within the scope of practice of the nursing assistant. Option C- This option is incorrect because operating and manipulating the ventilator settings to the physician's orders are a nurse's responsibility. Option D- This option is not correct because this is a critical assessment that should be done by the nurse. If the patient needed suctioning, again this is something that is the nurse's responsibility.

A patient arrives in the ER with suspected appendictis. Which of the following actions performed by the UAP caring for the patient would require further teaching in reguards to saftey for the patient? A) The UAP does not give the patient any fluids or foods. B) The UAP gives the patient a heating pack for comfort C) The UAP reminds the patient to stay in bed. D) The UAP allows the patient to lay in whatever position is most comfortable.

B) The UAP gives the patient a heating pack for comfort

The joint commission issues a guidelines regarding the use of restraints. In which case is a restraint properly used? A) the nurse positions a pt. in a supine position prior to applying wrist restraints. B) the nurse ensures that two fingers can be inserted between the restraint and the patient's ankle. C) the nurse applies a cloth restraint to the L hand of a patient with an IV catheter int he R wrist. D) the nurse ties an elbow restraint to the raised side rail of a patient's bed.

B) the nurse ensures that two fingers can be inserted between the restraint and the patient's ankle.

The client tells the nurse, "Every time I come to the hospital you hand me one of these Advance Directives. Why should I fill one out?" A. "You must fill this form out because Medicare laws require it" B. "An Advance Directive allows you to participate in decisions about your health care." C. "This paper will ensure no one can override your decisions" D. "It is part of the hospital admission policy"

B. "An Advance Directive allows you to participate in decisions about your health care." This is correct because this is part of the definition and point of creating an Advance Directive (AD). You are given a voice in your care when a circumstance comes that you become incapacitated and cannot make your own decisions. An AD allows for your decisions to already be made ahead of time and set for everyone involved in your health care know.

You're providing an in-service on transmission-based precautions to a group of nursing students. Which statement made by a student warrants re-education about the topic? A. "I will make sure that any patient who is in droplet precaution wears a surgical mask being transported." B. "Patients with airborne diseases such as Meningitis require a special room with negative air pressure." C. "I will always wear gown and gloves when entering a room of a patient in contact precautions." D. "If I provide care to patients with C. Diff, Norovirus, and Rotavirus infections, I will always wash my hands with soap and water, not hand sanitizer."

B. "Patients with airborne diseases such as Meningitis require a special room with negative air pressure."

Nurse Betina should begin screening for lead poisoning when a child reaches which age? A. 3 months B. 12 months C. 24 months D. 30 months

B. 12 months

At what age do we expect a baby to be able to roll from tummy to back? A. 1 year B. 6 months C. 9 months D. 3 months

B. 6 months

Which patients below are best assigned to the LPN? A. A 30-year-old male patient with active GI bleeding that requires multiple blood transfusions. B. A 78-year-old female with osteoporosis who needs assistance performing range if motion exercises and ambulation with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet D. a 55- year-old male patient who reports chest pain and has ST segment elevation on his EKG.

B. A 78-year-old female with osteoporosis who needs assistance performing range if motion exercises and ambulation with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet LPN should only be assigned to stable patients with predictable outcomes and do not require critical thinking or complex analysis. Option A and D are unstable patients that require close and constant care with decisions being based on how to interpret patient findings. Think E.A.T. (Evaluate, Assess, Teach) LPNs cannot do these task.

Which patients below are best assigned to the LPN? (SATA) A. A 30-year-old male patient with active GI bleeding that requires multiple blood transfusions. B. A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet. D. A 55-year-old male patient who reports chest pain and has ST segment elevation on his EKG.

B. A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet. Patients in B and C are in stable conditions making it appropriate for the nurse to delegate these tasks to the LPN. Patients in A and D are both unstable and require care that involves advanced intervention, assessment, and evaluation; none of which can be delegated to the LPN.

When auscultating lung sounds, which sounds upon inhalation are indicative of fluid in the air sacs of the lower lobes: A. Rhonchi B. Crackling/ Rales C. Stridor D. Wheezing

B. Crackling/ Rales

When developing a plan of care for a male adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on: A. Becoming industrious B. Establishing an identity C. Achieving intimacy D. Developing initiative

B. Establishing an identity

The nurse obtains a prescription from the health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP? A. Placing a safety knot in the safety device straps B. Safely securing the safety device straps to the side rails C. Applying safety device straps that do not tighten when force is applied against them D. Securing so that two fingers can slide easily between the safety device and the client's skin

B. Safely securing the safety device straps to the side rails

The nurse is caring for a confused patient with an IV catheter. The patient habitually tugs at the IV tubing with his left hand and has almost dislodged it. What is the LEAST amount of restraint that will still maintain the patient's safety? A. 2-point restraints on the arms only. B. Safety "mitt" for the left hand. C. Safety "mitts" for both hands. D. 4-point restraints for maximum safety.

B. Safety "mitt" for the left hand.

What precautions are necessary when caring for a patient with hepatitis A. Wearing a mask at all times B. Wearing gloves for direct care C. Placing the patient in a private room D. Gowning before entering the room

B. Wearing gloves for direct care

Age-related eye changes may include: A. increased visual accommodation. B. macular degeneration. C. non-preventable blindness as a result of glaucoma. D. decreased ability of pupil to respond to light changes.

B. macular degeneration.

The best overall rule for avoiding accidents with equipment in the hospital is for the nurse to: A.Always lock wheels on movable equipment B.Never operate equipment without prior instruction C.Always unplug equipment when moving the client D.Never use equipment without a person to assist you

B.Never operate equipment without prior instruction

A non-ambulatory patient weighing 120 lbs has just been transferred to the stroke unit. The nurse has to move the patient from the stretcher onto the bed. Which assistive device should the nurse use? A: Gait or transfer belt B: Slide board C: Wheelchair D: Mechanical lift

B: Slide board

You're making the patient assignments for the next shift. On your unit there are three LPN's and two nursing assistants. Which patients will you assign for the LPNs? (Select all that apply) A) A 70-year-old female patient who is expected to be discharged home with antibiotic therapy. B) A 43-year-old male patient newly admitted with diabetic ketoacidosis. C) A 60-year-old female patient with dementia who has an ileostomy and scheduled tube feedings. D) A 55-year-old female patient who has an order to remove a Foley catheter.

C) A 60-year-old female patient with dementia who has an ileostomy and scheduled tube feedings. D) A 55-year-old female patient who has an order to remove a Foley catheter. LPNs can perform these standard routine procedures and both option C and D include stable patient cases. Option A is incorrect because the registered nurse is required to perform discharge teaching and proper antibiotic self-administration education. Option B is incorrect because the patient being admitted is unstable and will require glucose monitoring and insulin drips which requires critical thinking and interpretation.

Which of the following are actions that can be taken in an Advanced Directive of Do not resuscitate (DNR): A) Attempt of pulmonary resuscitation if cardiac arrest occurs B) Attempt all available means to sustain life during cardiac arrest C) Attempt intubation and life support methods D) Do not put patient on life support E) Do not intubate

C) Attempt intubation and life support methods The definition of DNR, is that the patient requested no cardiopulmonary resuscitation occur during cardiac arrest. DNR is defined by American Nurses Association as no attempt at cardiopulmonary resuscitation during cardiac arrest. However, there are no limits on the care the patient is given prior to the cardiac arrest or death. In addition, the patient can still be placed on life support and intubated. (Miller, 2017)

A nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing which of the following is the most appropriate activity for this child? A) Large picture books B) A radio C) Crayons and coloring book D) A sports video

C) Crayons and coloring book

A nurse cares for the son of a Spanish speaking mother who was admitted to the PICU at 1600 for a near drowning accident. The mother is inconsolable and does not understand English. As the nurse, you want to communicate with the mother in the midst of the care her son is receiving. What would you do first? A) Use google translate on your phone to communicate with the mom. B) Ask the mom to call her daughter who speaks English so she can translate. C) Grab one of the hospital translators/translator machines as quickly as possible. D) Use SBAR to communicate with the physician after getting the context of the accident from the mother.

C) Grab one of the hospital translators/translator machines as quickly as possible. The first thing the nurse should do as the client is being stabilized is get a hospital approved translator or hospital translating system so the nurse can communicate with the mom. Using SBAR to communicate with the physician would be important after gathering the health history of the son and the context of what happened.

A client is diagnosed with methicillin-resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A. Reverse isolation B. Respiratory isolation C. Contact isolation D. Standard precautions

C. Contact isolation

The nurse plans to prepare the body of a client who has just died for visitation of family members. Which action does the nurse take first? A. Close the client's eyes. B. Place the client's dentures back in the mouth. C. Determine if a family member would like to assist. D. Remove any attached tubes and dressing

C. Determine if a family member would like to assist.

During a prenatal visit, a patient tells you her last menstrual period was May 21, 2022. Based on Naegele's Rule, when is the estimated due date of her baby? A. February 27, 2022 B. March 19. 2023 C. February 28, 2023 D. April 16, 2022

C. February 28, 2023

Client with paranoid schizophrenia admitted to hospital. They have not slept in three nights. Which nursing goal takes priority? A. Increase a sense of responsibility B. Increase independence C. Promote trust D. Promote rest

C. Promote trust

A 12-month-old arrives to the health clinic for a well visit. You're assessing the infant's developmental milestones. Select below all the milestones the child should be able to perform? A. Rides a tricycle B. Draws a triangle C. Pulls to a standing position and can take a few steps D. Follows simple commands like "wave bye-bye" E. Puts objects in a container F. Hits two small wooden blocks together G. Says 2-3 word sentences

C. Pulls to a standing position and can take a few steps D. Follows simple commands like "wave bye-bye" E. Puts objects in a container F. Hits two small wooden blocks together

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant? A. Discuss weight-loss strategies such as diet and exercise with the patient. B. Teach the patient how to set up the BiPAP machine before sleeping. C. Remind the patient to sleep on his side instead of his back. D. Administer modafinil (Provigil) to promote daytime wakefulness.

C. Remind the patient to sleep on his side instead of his back. A nursing assistant can remind the patient of the action that is already taught by a nurse. The answer A is not correct because discussing weight-loss strategies with the patient requires planning and teaching, which cannot be performed by a nursing assistant. The answer B is not correct because a nursing assistant cannot perform patient education. The answer D is not correct because a nursing assistant cannot perform medication administration.

After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A) A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. B) 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. C) 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics. D) A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.

D) A 50-year old with asthma who complains of shortness of breath after using a bronchodilator. A) This is not an urgent case and can be done after the nurse sees the other patients. B) In COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable. The patient is stable. C) This is incorrect. This is not an urgent case and can after the nurse sees the patient with shortness of breath. D) This is correct. The patient with asthma did not experience relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are most urgent.

An RN has a critical patient that needs constant monitoring. However, the RN also has other patients in need of care. Which tasks below could the RN delegate to the LPN to help continue the process of patient care? (SATA) A. Admitting and assessing the new admission B. Completing the discharge teaching to a patient going home C. Updating and evaluating the patient's plan of care D. Administering subcutaneous Heparin E. Obtaining a routine 12-lead EKG F. Collecting a stool specimen G. Flushing a central line with normal saline

D. Administering subcutaneous Heparin E. Obtaining a routine 12-lead EKG F. Collecting a stool specimen They are routine procedures that usually have predictable outcomes. RNs are responsible for performing assessments on new admissions, teaching, evaluating, flushing and maintain central lines, and updating the patient's plan of care.

"While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?" A. Green B. Red C. Yellow D. Black

D. Black

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib pad B. Turning on the overhead radiant warmer C. Closing the doors to the room D. Drying the infant in a warm blanket

D. Drying the infant in a warm blanket

In the pediatric population, what would be a developmental red flag in a infant that is 6 months old? A. Able to eat finger foods B. Fear of strangers C. No object permanence D. Head lag while body is in seated position

D. Head lag while body is in seated position

What is the MAIN component of maintaing surgical asepsis during care? A. Scrubbing down with Chlorahexidine before encountering the patient. B.Utilization of disinfectants on surgical equipment C. Hand hygeine D. Only allowing a sterile object touch another sterile object

D. Only allowing a sterile object touch another sterile object

mily is talking to her 6 year old sister Julia. She asks why the sun shines so bright? Julia answers that it always keeps her warm. What stage in the cognitive theory of development explains this? A. Formal Operational B. Concrete Operational C. Sensorimotor D. Preoperational

D. Preoperational

You are caring for a group of elderly clients, many of whom are affected with multiple chronic disorders and are also, at times, affected with some acute disorders that require medical and nursing attention. As you are caring for these clients some will need a new medication regimen for an acute disorder. You should consider that fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a(n): Increased creatinine clearance Impaired immune system Decreased hepatic metabolism Increased bodily fat

Decreased hepatic metabolism

The nurse observes a student nurse assess neonatal clients in the nursery. Which student nurse action requires intervention by the nurse? Documenting a negative red light reflex in a neonate who is 2 days old. Testing the tonic neck reflex by lying the neonate supine and turning the head to one side. Testing the rooting reflex by stroking the corner of the neonate's mouth. Documenting a positive Babinski reflex in a neonate who is 1-day old.

Documenting a negative red light reflex in a neonate who is 2 days old.

The parent of a five-week-old infant brought their child into the emergency department reporting that the infant refuses to suckle and has been vomiting. The healthcare provider suspects hydrocephalus. Which finding(s) should the nurse expect. SATA Head circumference of 38 cm Low pitched cry Downward facing eyes Amblyopia Widely separated cranial sutures

Downward facing eyes Widely separated cranial sutures

While teaching a 10 year-old child about their impending heart surgery, the nurse should: Provide a verbal explanation just prior to the surgery Provide the child with a booklet to read about the surgery Introduce the child to another child who had heart surgery three days ago Explain the surgery using a model of the heart

Explain the surgery using a model of the heart

The nurse assesses a client who is at 24 weeks gestation. Which finding causes the nurse to be most concerned? Fetal heart rate of 130 to 140 beats per minute. Fundal height at three fingers below the umbilicus Fetal movements felt faintly on lower part of abdomen. The client reports backache and leg cramps when sleeping.

Fundal height at three fingers below the umbilicus

A newly admitted patient reveals that she is pregnant for the fourth time. For her first pregnancy she delivered at 39 weeks, for her second pregnancy she had a miscarriage at 18 weeks, and for her third pregnancy she delivered at 34 weeks. What is this patient's GTPAL? G41112 G42012 G31112 G32012

G41112

A nursing student helps an older Islamic patient order their lunch for the first time. The nurse should interfere when the student nurse selects which of the following: Chicken tenders, broccoli, and macaroni salad. Honey glazed pork chops, rice, and carrots Caesar salad with grilled chicken and mac & cheese Meatloaf, green beans, and mashed potatoes

Honey glazed pork chops, rice, and carrots

A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? The client should be placed in a negative pressure room Infection requires close contact; therefore, the door may remain open Transmission is highly likely, so the client should wear a mask at all times Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and gown.

Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and gown.

You are the charge nurse on the pediatric unit when a pediatrician calls wanting to admit a child with rubeola (measles). Which of these factors is of most concern in determining whether to admit the child to your unit? No negative-airflow rooms are available on the unit The infection control nurse liaison is not on the unit today There are several children receiving chemotherapy on the unit The unit is not staffed with the usual number of RNs

No negative-airflow rooms are available on the unit

The nurse providers care for a client with an abdominal wound. The nurse notes there is purulent drainge from the wound. Which action does the nurse take first? Contacts the health care provider Places the client on contact precautions Irrigates the wound Asks the client to identify the level of pain on a numeric scale

Places the client on contact precautions

A catastrophic disaster has occured 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. A wounded victim is unable to walk, has a respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color according to the disaster triage tag system? Green Red Yellow Black

Red

Recently, there has been an increase in Clostridium difficile in an inpatient medical unit. What is the best method of preventing further spread among patients? Assign patients to private rooms Reinforce consistent hand hygiene Clean rooms with bleach ever day Administer prophylactic antibiotics

Reinforce consistent hand hygiene

The nurse provides care for a client newly diagnosed with MRSA. Which action does the nurse take when following contact precautions? (SATA) Remove protective gown in client's room Remove gloves before leaving client's room Perform hand hygiene before and after patient care Assign to a room with a client with the same diagnosis Apply an N95 respirator mask when entering the client's room Wear a mask if working within 3 feet of the client

Remove protective gown in client's room Remove gloves before leaving client's room Perform hand hygiene before and after patient care Assign to a room with a client with the same diagnosis

The nurse is assessing a six month old child. Which developmental skills are normal and should be expected? Pulling up to a standing position Can feed self with a spoon Sits alone Speaks in short sentences

Sits alone

The nurse was recently assigned to conduct home health visit for a 75 year old patient. The nurse understands that this patient is subject to visual changes, which of the following interventions address visual changes with age? Teaching the patient to wear their glasses at all times Opening the blinds and curtains in the patient's home uncluttering hallways providing adequate lighting within the home Placing the bed at the lowest position

Teaching the patient to wear their glasses at all times uncluttering hallways providing adequate lighting within the home

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? The client fell out of bed The client climbed over the side rails The client was found lying on the floor The client became restless and tried to get out of bed

The client was found lying on the floor

The nurse on the behavioral health unit negotiates a behavior modification contract with an adolescent client diagnosed with anorexia nervosa. The nurse determines further teaching is necessary when the client makes which statement? Exercise is not allowed until I reach my target weight The faster I gain weight, the faster I will return to school. I will eat at each mealtime because it's my only option. I know someone will watch me during eating and after I eat.

The faster I gain weight, the faster I will return to school.

An older patient is diagnosed with a fractured humerus and is recovering at home. Which nursing observation in the home requires an immediate intervention? The bathroom is equipped with grab bars Small area rugs have been removed The patient ambulates wearing socks The stairs are well lighted

The patient ambulates wearing socks

The parent of two school-age children tells the nurse the spouse has recently become unemployed. The patient reports feeling depressed. The nurse understands which statement is true? The spouse's unemployment is a significant potential stressor. The spouse's unemployment is irrelevant. Unemployment is mainly a factor in development crises. The patient is using the spouse's unemployment to avoid personal problems.

The spouse's unemployment is a significant potential stressor.

Multiple clients from a plane crash are transferred to the hospital. The nurse triages clients in the ED. Using the principle of mass casualty, which client does the nurse see first? The older adult client with a fractured pelvis and bilateral femur fractures; client is not breathing and unresponsive. The young adult client with burns to the chest and face area; the client is responsive to stimuli and the client's airway is patent. The school-age client with elbow dislocation; the client is conversing with parents and staff appropriately. The preschool-age client with a hip dislocation; the client is crying loudly although is temporarily distractable.

The young adult client with burns to the chest and face area; the client is responsive to stimuli and the client's airway is patent.

The nurse provides care for a client admitted for abdominal surgery. During the admission interview, the client admits to drinking 1 pint (473 mL) of vodka per day. Which is the BEST initial response by the nurse? Why do you drink a whole pint of vodka per day? How long have you been drinking the quality of alcohol? Do you drink with someone or at a particular place? When did you have your last drink of alcohol?

When did you have your last drink of alcohol?

The family of a hospitalized client demonstrates understanding of the teaching about "advance directive" and "power of attorney" when they make which statements? Select all that apply. a) "Advance directives give instructions about future medical care and treatment." b) "If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." c) "Ethics experts agree that the family is the sole deciding factor when the client is competent." d) "Medical power-of-attorney gives primarily financial access to the designee." e) "Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself." f) "Advance directives give details about the client's past medical history."

a) "Advance directives give instructions about future medical care and treatment." b) "If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." e) "Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself." Advance directives are written documents stating a person's wishes regarding health care in the case that he/she is unable to decide for his/herself. Power of attorney is a written authorization that allows another person to represent a person on their behalf and does not include finances. These documents relate to current medical matters and does not include a past medical history.

Question: Which action(s) violate HIPAA? (Select all that apply) a) Discussing the patient's comatose condition with his father-in-law b) Discussing the outcome of a patient's test with another nurse from the unit while in a crowded elevator c) Relaying information about the patient's concern to the nurse who will care for him on the next shift d) Relaying a complaint about the quality of nursing care by the patient's wife to the charge nurse e) Updating your social media site about a difficulty clinical day, including hospital and patient's diagnosis, but NOT the patient's name

a) Discussing the patient's comatose condition with his father-in-law b) Discussing the outcome of a patient's test with another nurse from the unit while in a crowded elevator e) Updating your social media site about a difficulty clinical day, including hospital and patient's diagnosis, but NOT the patient's name All patient medical information should be kept private and confidential. Discussing private patient information with members of his family counts as an invasion of the patient and their medical information especially if the patient did not consent to having the release of their medical information be sent to family members. Talking about the patient's test results with another nurse from the unit in general is another way to break the patient's privacy, as that the other nurse is not taking care of that patient and should not have access to the patient's medical information. Additionally, being in a crowded elevator means that there are other people who could be listening to the private patient information that is being talked about, and thus counts as an invasion of the patient's privacy. Lastly, posting about a patient even though one is not explicitly saying the name of the patient violates the patient's privacy. Posting information like this could lead to the patient's name and other private information being exposed to the public.

The nurse is aware that the age at which the posterior fontanelle closes is ___ months. a. 2 to 3 b. 3 to 6 c. 6 to 9 d. 9 to 12

a. 2 to 3

The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/ LVN being supervised by a nurse? (Select all that apply.) a. Reminding the client to avoid commercial mouthwashes b. Encouraging mouth rinsing with warm saline c. Observing the lips, tongue, and mucous membranes d. Providing mouth care every 2 hours while the client is awake. e. Seeking a dietary consult to increase fluids on meal trays

a. Reminding the client to avoid commercial mouthwashes b. Encouraging mouth rinsing with warm saline c. Observing the lips, tongue, and mucous membranes d. Providing mouth care every 2 hours while the client is awake.

There is a fire in the hospital and the ICU nurse is trying to figure out the best course of action for her two patients on ventilators. What should she do first? a.) Pull the fire alarm b.) Close the fire doors on her side of the unit c.) Extinguish the fire d.) Evacuate her patients from the floor via transport elevator

a.) Pull the fire alarm

A 70-year-old immobile patient, who has right-sided weakness caused by a recent stroke, weighs approximately 250 pounds and needs to be moved up in bed. Which of the following actions should the nurse take? (Select all that apply.) a.Summon at least one other person to assist. b.Obtain a mechanical lift. c.Perform the move by himself, because it should not be too difficult. d.Obtain a lift sheet. e.Put the bed in semi-Fowler's position .f.Place the patient flat on her back.

a.Summon at least one other person to assist d.Obtain a lift sheet. .f.Place the patient flat on her back.

Which of the following best describes the continuity of care? a. "Set of activities intended to improve patient care and reduce need for medical services." b. "It involves patient-centered high quality care across all clinical settings" c. "A framework used to systematically improve care." d. "Action or process of declining the importance or urgency."

b. "It involves patient-centered high quality care across all clinical settings" Maintaining the continuity of care from the start of admission to discharge until home care services is part of continuity of care. This will identify current clients needs and moving the client to its appropriate clinical area, appropriate level of care, appropriate healthcare facility in an effective manner. This also ensure safety and quality care received by the patient.

"A young child is being evaluated in the Emergency Department for injuries her mother reports resulted from a fall down the stairs. Which of these findings indicates that physical abuse may be a chronic problem for the child?" a. The mother's description of the child as being 'clumsy' b. Several fractures revealed on x-ray in varying degrees of healing c. Clinging to her mother as she attempted to leave the examining room d. Struggling with the staff when attempts to obtain a blood specimen were made

b. Several fractures revealed on x-ray in varying degrees of healing

Which age group has the greatest potential to regress during hospitalization? a. Adolescent b. Toddler c. Infant d. Young adult

b. Toddler

The nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurses priority at this time? a.obtain a walker for the client to use to transfer back to bed b. determine the clients ability to help with the transfer c.use a transfer belt to assist the client back into bed d.call for additional staff to assist with the transfer

b. determine the clients ability to help with the transfer

The nurse is teaching a client who is facing a difficult healthcare choice. Which should the nurse identify as the intended goal of the action? A. enabling b. empowerment c. informed consent d. codependency

b. empowerment Nurses advocate for clients in order to protect their rights and empower them to participate in making informed health care decisions. Enabling is not the intended goal for this client. Principles of informed consent are not involved here. Codependency is the opposite of what advocacy seeks to achieve.

The nurse is assessing a client's hearing acuity.During the voice test, the nurse stands approximately 2 feet behind and to the side of the client.Why should the nurse take this position during the vocal test? a.to facitate sound conduction to the tested ear only b.to simulate the distance between people during social interaction c.to assess the client's ability to discriminate sound d.to deliver a high -pitched sound toward the tested ear

b.to simulate the distance between people during social interaction

A 6 year old female is diagnosed with Varicella. What type of isolation precautions will be initated for this patient? a) Droplet b) Airborne c) Airborne and contact d) Droplet and contact

c) Airborne and contact

"Forty-eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following?" a) Taking in b) Letting go c) Taking hold d) Resolution

c) Taking hold

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? a. The client fell out of bed b. The client climbed over the side rails c. The client was found lying on the floor d. The client became restless and tried to get out of bed.

c. The client was found lying on the floor

Which stage of development is most unstable and challenging regarding development of personal identity? a. infancy b. childhood c. adolescence d. toddlerhood

c. adolescence

The nurse observes a group of children clients at play. Which type of play does the nurse identify as typical for toddlers? a.) Four children playing dodgeball b.) Three children playing tag c.) Two children in the sandbox building castles side by side. d.) One child digging a hole, another child blowing bubbles

c.) Two children in the sandbox building castles side by side.

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client? a. Reverse isolation b. Respiratory isolation c. Standard precautions d. Contact isolation

d. Contact isolation

When an elderly patient is brought into the Emergency Department by family members who reported a fall the nurse became suspicious that the patient had suffered physical abuse. The patient denied that she had been abused. Her denial is most likely based on her: a. Feeling that she deserved the physical abuse b. Strong belief that nothing could be done to help her c. Lack of trust that the situation could ever be changed d. Fear of the possibility of being removed from her family

d. Fear of the possibility of being removed from her family

You are the nurse assigned to complete a telephone triage. A client just called in to report that they ate a cookie which caused them a couple symptoms and they are asking for help. The client is reporting experiencing hives, and swelling with no respiratory distress or symptoms of anaphylactic shock. What is the appropriate inital action that the nurse should suggest to the patient? call 911 take a antihistamine avoid eating anymore of the cookie apply cold compress to the swollen areas

take a antihistamine

A nurse is volunteering in an indigent clinic. She is seeing a patient whom she suspects has active tuberculosis. In this disease process, which of the following body systems serves as both the reservoir and portal of entry for this infection? the gastrointestinal system the respiratory system the hematologic system the integumentary system

the respiratory system