FON FINAL EXAM Saunders Book

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)?

A client who requires frequent ambulation

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

"I have a legal obligation to report this type of abuse."

The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up?

A reddish-purple mark on the neck

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which would be the initial nursing action?

Activate the agency emergency response plan.

A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2°C (97.2°F) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action must the nurse take first?

Attempt to arouse the client

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will.

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse needs to place the client in which position for insertion? 1. Right side

High Fowler's position

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding the next dose of warfarin

An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed?

Leaving the rate of the heparin infusion as is

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side-lying position. The nurse understands that the purpose of this intervention is to accomplish which outcome?

Limit bleeding from the biopsy site

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. Which of the following describes the team-based model of nursing practice?

Nursing staff are led by the nurse when providing care to a group of clients.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks?

Perform follow-up with each staff member regarding the performance and outcome of the task.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse would plan to take which action?

Report the information to a nursing supervisor.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

A nurse lawyer provides an education session to the nursing staff regarding client rights with an emphasis on invasion of these rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by a staff nurse, indicates an understanding of a violation of this client right?

Taking photographs of the client without consent

Which teaching method is most effective when providing instruction to members of special populations?

Teach-back

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left modified left lateral recumbent position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily.

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the assistive personnel (AP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?

The restraint straps are safely secured to the side rails.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Transport the client to the operating department immediately without obtaining an informed consent.

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention?

240 mg/dL

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would be reported before administering the dose of furosemide?

3.2 mEq/L

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client would the nurse assign to the assistive personnel (AP)?

A client who requires a 24-hour urine collection

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Arranging for home health care

A licensed practical nurse (LPN) is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating their pain."

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How would the nurse respond?

"Living in a prison can predispose a person to different health conditions."

The nurse employed in an emergency department (ED) is assigned to assist with the triage of clients arriving at the ED. The nurse would assign priority to which client?

A client with chest pain who states that they just ate pizza that was made with a very spicy

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider (PHCP) to inform them of the occurrence. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?

Activate the fire alarm.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse must perform?

Aim at the base of the fire.

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action at this time?

Remain with the family member without discussing funeral arrangements.

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse needs to plan to maintain bed rest for this client in which position?

Supine with head elevation no greater than 30 degrees

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse needs to plan to place the client in which position?

Supine, with the residual limb supported with pillows

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse collect data from first?

A client receiving oxygen who is having difficulty breathing

The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?

A client who is dependent on a ventilator

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action would the nurse instruct the mother to take first?

Call the poison control center.

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, must be addressed first?

Complaints of pain associated with numbness and tingling in both feet

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action?

Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value?

2000 mm3

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax?

Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3. The nurse needs to take which action after seeing the laboratory results?

Place the normal report in the client's medical record

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How would the nurse determine that the restraints are not too constrictive?

Place two fingers under the restraint to determine snugness.

The nurse assisting in planning care for a military veteran must prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

Post-traumatic stress disorder

A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?

Preventing and recognizing hyperglycemia