Foundations of Nursing Practice UNIT I/Nursing ATI questions

¡Supera tus tareas y exámenes ahora con Quizwiz!

Safe, Effective Care Environment Which nursing activities may be safely delegated to competent unlicensed nursing personnel? Select all that apply. A.Discharge teaching B.Blood pressure monitoring C.Gastrostomy feeding D.Urinary catheterization E.Oxygen administration F.Ambulation assistance

Answer: C, D Rationale: Choices B and E are already part of the routine care of the AP which does not meet the definition of delegated responsibilities. Discharge teaching (Choice A) is not an activity, skills, or procedure and requires an RN to perform. If the AP is trained and competent to perform a gastrostomy tube feeding or oxygen administration, the nurse may delegate those skills. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

2. A nursing student is preparing to transfer a client with limited weight bearing from the bed to the chair. Which action by the student would require intervention from the nurse? A. Places the bed at hip level. B. Applies a gait belt to the client. C. Extends arms to reach out to client. D. Creates a wide base with the feet.

Answer: C Rationale: The nurse will keep the client as close the body as possible to prevent reaching. Extending the arms out to reach for the client is not safe patient handling and mobility which would require the nurse to intervene. Placing the bed at hip level is appropriate for moving clients, applying a gait belt is also appropriate to add balance and stability, and creating a wide base with the feet creates stability. Cognitive Level: Application Integrated Process: Safe and Effective Care Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

A nurse instructor outlines the criteria establishing nursing as a profession. What teaching point correctly describes this criteria? Select all that apply. A. Nursing is composed of a well-defined body of general knowledge B. Nursing interventions are dependent upon medical practice C. Nursing is a recognized authority by a professional group D. Nursing is regulated by the medical industry E. Nursing has a code of ethics F. Nursing is influenced by ongoing research

c, e, f. Nursing is recognized increasingly as a profession based on the following defining criteria: well-defined body of specific and unique knowledge, strong service orientation, recognized authority by a professional group, code of ethics, professional organization that sets standards, ongoing research, and autonomy and self-regulation. CHAPTER 1 Introduction to Nursing

USING PROFESSIONAL COMMUNICATION IN THE NURSING PROCESS

The ability to communicate with patients, other nurses, and other health care professionals is essential for effective use of the nursing process. Knowledge of the communication process and effective communication techniques is fundamental to all steps of the nursing process. At the same time, the nursing process provides the guidance and direction needed to communicate in a professional manner clearly, effectively, and compassionately. Assessing The major focus of assessment is to gather information in both verbal and nonverbal communication forms. Before the assessment, the nurse should determine if the patient needs any assistive devices in order to communicate effectively and understand conversations (e.g., hearing aid, glasses, etc.). Identify the patient's preferred language and secure an interpreter if one is needed. The written word is used to obtain patient data and when reading patients' records or charts before meeting them. The spoken word is used to give and to receive reports to and from other health personnel. This is commonplace when admitting a patient to a hospital unit or before visiting the patient at home. One-to-one communication is used with patients to obtain thorough nursing histories and physical examinations. Effective communication techniques, as well as observational skills, are used extensively during this phase. The data collected verbally and nonverbally are analyzed, documented, and then passed on to the appropriate people through oral and written communication. Diagnosing An assessment of the patient may lead to the development of one or more nursing diagnoses relate to alterations in communication. An impaired ability to communicate may contribute to the development of other nursing diagnoses as well. Following the formulation of the nursing diagnoses, the nurse communicates findings to other nursing professionals through the use of the written and spoken word. The written diagnosis becomes a permanent part of the patient's health record. An example of a nursing diagnosis with related etiologic factors and defining characteristics can be found in the box titled Examples of NANDA-I Nursing Diagnoses: Communication. Outcome Identification and Planning The planning step requires communication among the patient, nurse, and other team members as mutually agreed-upon outcomes are developed and interventions are determined. Because a nurse is rarely able to implement all parts of a plan alone, oral and written communication is needed to inform others of what needs to be done to meet the set objectives or goals. The formal written nursing care plan is a form of communication. Without communication, the nursing plan could not be implemented and continuity in care would not be possible. Implementing Nurses assume many roles when they implement the nursing care plan. Verbal and nonverbal communication methods enhance basic caregiving measures and are used to teach, counsel, and support patients and their families during the implementation phase. Even a simple nursing intervention, such as "encourage patient to drink 100 mL of fluid every hour while awake," requires countless messages to be sent and received between the nurse and the patient and the nurse and other nurses and health care providers. The nurse explains the importance of an adequate fluid intake, along with the amount and frequency of intake. The nurse communicates the plan to others involved in the care of the patient. The patient, in turn, speaks of his or her ability or inability to meet targeted objectives. The patient's verbal and nonverbal messages are assessed during each nurse-patient interaction. The implementation of the nursing care plan is then documented in the patient's record. Evaluating Nurses often rely on verbal and nonverbal cues from patients to verify whether patient objectives or goals have been achieved. Communication, through the exchange of positive and negative messages between the nurse and the patient, also facilitates the revision of parts of the nursing care plan.

25. Which client should the nurse expect the health-care provider to prescribe chlordiazepoxide (Librium), a benzodiazepine? 1. A client addicted to cocaine. 2. A client addicted to heroin. 3. A client addicted to amphetamines. 4. A client addicted to alcohol.

Librium would not help a client addicted to cocaine. Methadone, not Librium, blocks the crav- ing for heroin. Librium would not help a client addicted to amphetamines. ✅4. Librium is the drug of choice for pre- venting neurological complications and delirium tremens, which is a life- threatening complication of alcohol withdrawal. Comprehensive Examination. Pharmacology Success

Question 2 of 13 A nurse gives report about a client whose pain in uncontrolled and suggests that the client receive continuous analgesic administration rather than PRN analgesics. Which step of the SBAR hand-off report is the nurse using? 1. S 2. R 3. B 4. A

S R stands for recommendation or request for a new modality or treatment to better manage the client's problem. ✅CORRECT R R stands for recommendation or request for a new modality or treatment to better manage the client's problem. B R stands for recommendation or request for a new modality or treatment to better manage the client's problem. A R stands for recommendation or request for a new modality or treatment to better manage the client's problem. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

28. The nurse is administering 1.0 inch of Nitropaste, a coronary vasodilator. How much paste should the nurse apply to the application paper? 1. 1/2" 2. 1" 3. 11/2" 4. 2"

This would be half the dose prescribed. ✅2. The line is in increments of 0.5 (1/2 inch) and the order is 1 inch. This would be 11/2 inches, which is not the correct dose. This would be 2 inches, which is not the correct dose Comprehensive Examination. Pharmacology Success

Acronym —-> TEACH

T: Tune into the patient E: Edit patient information A: Act on every teaching moment C: Clarify often H: Honor the patient as a partner in the education process Like other clinical interventions, effective patient teaching demands analytic and problem-solving skills. To maximize the effectiveness of patient teaching teach acronym is used

Physiological Integrity A nurse conducts an assessment of an older adult's medications, including both prescription and over-the-counter drugs. Which drug would the nurse identify as being potentially inappropriate for older adults? A.Vitamin D B.Losartan C.Nortriptyline D.Hydrochlorothiazide (HCTZ)

Answer: C Rationale: Choice C is a tricyclic antidepressant that has anticholinergic effects causing constipation, urinary retention, and confusion. Visual disturbances and dry mouth are also common side effects. Therefore, this drug in not appropriate for older adults. Choice A is a vitamin that can help prevent bone loss; choices B and D are used to manage hypertension. Patients on losartan are monitored for orthostatic hypotension and patients on the diuretic HCTZ are monitored for sodium and potassium loss. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

1.The nurse is conducting an assessment of an older adult living in the community. Which assessment findings are considered usual physiologic changes of aging? Select all that apply. A.Dementia B.Relocation stress C.Urinary incontinence D.Presbyopia E.Obesity

Answer: D Rationale: All of the other choices are common health problems that occur in the older adult population but are not usual physiologic changes that older adults should expect as part of the aging process. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

3 of 15 A client with a gunshot wound is brought to the emergency department (ED). Which nursing intervention is appropriate? Blood and body fluid precautions Metal detector screening of the client Admission to a negative-pressure room Placement of a security guard

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

2. A nurse is using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model PET as a clinical decision-making tool when delivering care to patients. Which steps reflect the intended use of this tool? Select all that apply. A. A nurse recruits an interprofessional team to develop and refine an EBP question. B. A nurse draws from personal experiences of being a patient to establish a therapeutic relationship with a patient. C. A nurse searches the Internet to find the latest treatments for type 2 diabetes. D. A nurse uses spiritual training to draw strength when counseling a patient who is in hospice for an inoperable brain tumor. E. A nurse questions the protocol for assessing postoperative patients in the ICU. F. A nursing student studies anatomy and physiology of the body systems to understand the disease states of assigned patients.

a, c, e. The JHNEBP model is a powerful problem-solving approach to clinical decision making, and is accompanied by user-friendly tools to guide individual or group use. It is designed specifically to meet the needs of the practicing nurse and uses a three-step process called PET: practice question, evidence, and translation. The goal of the model is to ensure that the latest research findings and best practices are quickly and appropriately incorporated into patient care. Steps in PET include, but are not limited to, recruiting an interprofessional team, developing and refining the EBP question, and conducting internal and external searches for evidence. CHAPTER 2 Theory, Research, and Evidence-Based Practice

4. A charge nurse meets with staff to outline a plan to provide transcultural nursing care for patients in their health care facility. Which theorist promoted this type of caring as the central theme of nursing care, knowledge, and practice? A. Madeline Leininger B. Jean Watson C. Dorothy E. Johnson D. Betty Newman

a. Madeline Leininger's theory provides the foundations of transcultural nursing care by making caring the central theme of nursing. Jean Watson stated that nursing is concerned with promoting and restoring health, preventing illness, and caring for the sick. The central theme of Dorothy E. Johnson's theory is that problems arise because of disturbances in the system or subsystem or functioning below optimal level. Betty Newman proposed that humans are in constant relationship with stressors in the environment and the major concern for nursing is keeping the patient system stable through accurate assessment of these stressors. CHAPTER 2 Theory, Research, and Evidence-Based Practice

Nursing in the United States is regulated by the state nurse practice act. What is a common element of each state's nurse practice act? A. Defining the legal scope of nursing practice B. Providing continuing education programs C. Determining the content covered in the NCLEX examination D. Creating institutional policies for health care practices

a. Nurse practice acts are established in each state to regulate the practice of nursing by defining the legal scope of nursing practice, creating a state board of nursing to make and enforce rules and regulations, define important terms and activities in nursing, and establish criteria for the education and licensure of nurses. The acts do not determine the content covered on the NCLEX, but they do have the legal authority to allow graduates of approved schools of nursing to take the licensing examination. The acts also may determine educational requirements for licensure, but do not provide the education. Institutional policies are created by the institutions themselves.

5. A student nurse interacting with patients on a cardiac unit recognizes the four concepts in nursing theory that determine nursing practice. Of these four, which is most important? A. Person B. Environment C. Health D. Nursing

a. Of the four concepts, the most important is the person. The focus of nursing, regardless of definition or theory, is the person. CHAPTER 2 Theory, Research, and Evidence-Based Practice

According to the National Advisory Council on Nurse Education and Practice, what is a current health care trend contributing to 21st century challenges to nursing practice? A. Decreased numbers of hospitalized patients B. Older and more acutely ill patients C. Decreasing health care costs owing to managed care D. Slowed advances in medical knowledge and technology

b. The National Advisory Council on Nurse Education and Practice identifies the following critical challenges to nursing practice in the 21st century: A growing population of hospitalized patients who are older and more acutely ill, increasing health care costs, and the need to stay current with rapid advances in medical knowledge and technology CHAPTER 1 Introduction to Nursing

A nurse is caring for a patient in the ICU who is being monitored for a possible cerebral aneurysm following a loss of consciousness in the emergency department (ED). The nurse anticipates preparing the patient for ordered diagnostic tests. What aspect of nursing does this nurse's knowledge of the diagnostic procedures reflect? A. The art of nursing B. The science of nursing C. The caring aspect of nursing D. The holistic approach to nursing

b. The science of nursing is the knowledge base for care that is provided. In contrast, the skilled application of that knowledge is the art of nursing. Providing holistic care to patients based on the science of nursing is considered the art of nursing. CHAPTER 1 Introduction to Nursing

A nurse practicing in a primary care center uses the ANA's Nursing's Social Policy Statement as a guideline for practice. Which purposes of nursing are outlined in this document? Select all that apply. A. A description of the nurse as a dependent caregiver B. The provision of standards for nursing educational programs C. A definition of the scope of nursing practice D. The establishment of a knowledge base for nursing practice E. A description of nursing's social responsibility The regulation of nursing research

c, d, e. The ANA Social Policy Statement (2010) describes the social context of nursing, a definition of nursing, the knowledge base for nursing practice, the scope of nursing practice, standards of professional nursing practice, and the regulation of professional nursing. CHAPTER 1 Introduction to Nursing

7. When conducting quantitative research, the researcher collects information to support a hypothesis. This information would be identified as: A. The subject B. Variables C. Data D. The instrument

c. Data refer to information that the researcher collects from subjects in the study (expressed in numbers). A variable is something that varies and has different values that can be measured. Instruments are devices used to collect and record the data, such as rating scales, pencil-and-paper tests, and biologic measurements. CHAPTER 2 Theory, Research, and Evidence-Based Practice

8. A nurse is conducting quantitative research to examine the effects of following nursing protocols in the emergency department (ED) on patient outcomes. This is also known as what type of research? A. Descriptive B. Correlational C. Quasi-experimental D.Experimental

c. Quasi-experimental research is often conducted in clinical settings to examine the effects of nursing interventions on patient outcomes. Descriptive research is often used to generate new knowledge about topics with little or no prior research. Correlational research examines the type and degree of relationships between two or more variables. Experimental research examines cause-and-effect relationships between variables under highly controlled conditions. CHAPTER 2 Theory, Research, and Evidence-Based Practice

10. A nurse is formulating a clinical question in PICOT format. What does the letter P represent? A. Comparison to another similar protocol B. Clearly defined, focused literature review of procedures C. Specific identification of the purpose of the study D. Explicit descriptions of the population of interest

d. The P in the PICOT format represents an explicit description of the patient population of interest. I represents the intervention, C represents the comparison, O stands for the outcome, and T stands for the time. CHAPTER 2 Theory, Research, and Evidence-Based Practice

A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching? mcg q.d. mL PO

mcg In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module 4. This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "µg" was previously used to indicate micrograms, which can be mistaken as the abbreviation for "milligrams (mg)," resulting in medical errors. The Joint Commission has recommended the use of "mcg" to indicate micrograms. This is an acceptable abbreviation; therefore, additional teaching is not needed. ✅q.d. MY ANSWER In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module 4. This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "q.d." was previously used to indicate every day, which can be mistaken as the abbreviation for "four times daily (qid)," resulting in medical errors. The Joint Commission has recommended the use of "daily" to indicate every day. This is not an acceptable abbreviation; therefore, additional teaching is needed. mL In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module 4. This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "cc" was previously used to indicate cubic centimeters, which can be mistaken as the abbreviation for "units (u)," resulting in medical errors. The Joint Commission has recommended the use of "mL" to indicate milliliters. This is an acceptable abbreviation; therefore, additional teaching is not needed. PO In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module 4. This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "Per os" was previously used to indicate orally, which can be mistaken as the abbreviation for "left eye (OS)," resulting in medical errors. The Joint Commission has recommended the use of "PO" to indicate orally. This is an acceptable abbreviation; therefore, additional teaching is not needed.

2. A nurse working in a hospital setting cares for patients with acute and chronic conditions. Which disease states are chronic illnesses? Select all that apply. A. Diabetes mellitus B. Bronchial pneumonia C. Rheumatoid arthritis D. Cystic fibrosis E. Fractured hip F. Otitis media

✅a, c, d. Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are permanent changes caused by irreversible alterations in normal anatomy and physiology, and they require patient education along with a long period of care or support. Pneumonia, fractures, and otitis media are acute illnesses because they have a rapid onset of symptoms that last a relatively short time. CHAPTER 3 Health, Wellness, and Health Disparities

3.A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. A. A Native American patient B. An African-American patient C. An Alaska Native D. An Asian patient E. A White patient F. A Hispanic patient

✅a, c, e, f. Native Americans, Alaska Natives, Hispanics, and Whites are more prone to developing diabetes mellitus. African Americans are prone to hypertension, stroke, sickle cell anemia, lactose intolerance, and keloids. Asians are prone to hypertension, liver cancer, thalassemia, and lactose intolerance. CHAPTER 5 Cultural Diversity

10.A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply. A. Advocacy is the protection and support of another's rights. B. Patient advocacy is primarily performed by nurses. C. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities. D. Nurse advocates make good health care decisions for patients and residents. E. Nurse advocates do whatever patients and residents want. F. Effective advocacy may entail becoming politically active.

✅a, c, f. Advocacy is the protection and support of another's rights. Among the patients with special advocacy needs are the very young and the older adult, those who are seriously ill, and those with disabilities; this is not a comprehensive list. Effective advocacy may entail becoming politically active. Patient advocacy is the responsibility of every member of the professional caregiving team—not just nurses. Nurse advocates do not make health care decisions for their patients and residents. Instead, they facilitate patient decision making. Advocacy does not entail supporting patients in all their preferences. CHAPTER 6 Values, Ethics, and Advocacy

2. In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply. A. A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. B. A nurse treats all patients the same whether or not they come from a different culture. C. A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. D. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. E. A nurse directs interview questions to an older adult's daughter even though the patient is capable of answering them. F. A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

✅a, d. Cultural imposition occurs when a hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily, and when a Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. Cultural blindness occurs when a nurse treats all patients the same whether or not they come from a different culture. Culture conflict occurs when a nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for Jewish patients to get a special tray of their favorite foods. When a nurse refuses to respect an older adult's ability to speak for himself or herself, or if the nurse refuses to treat a patient based on that patient's sexual orientation, the nurse is engaging in stereotyping. CHAPTER 5 Cultural Diversity

2. Newly hired nurses in a busy suburban hospital are required to read the state nurse practice act as part of their training. Which topics are covered by this act? Select all that apply. A. Violations that may result in disciplinary action B. Clinical procedures C. Medication administration D. Scope of practice E. Delegation policies F. Medicare reimbursement

✅a, d. Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act. Nurse practice acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through federal legislation. CHAPTER 7 Legal Dimensions of Nursing Practice

6. A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two children. Which interview questions directed to the single mother could the nurse use to assess the affective and coping family function? Select all that apply. A. Who is the person you depend on for emotional support? B. Who is the breadwinner in your family? C. Do you plan on having any more children? D. Who keeps your family together in times of stress? E. What family traditions do you pass on to your children? F. Do you live in an environment that you consider safe?

✅a, d. The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. Asking who provides emotional support in times of stress assesses the affective and coping function. Assessing the breadwinner focuses on the economic function. Inquiring about having more children assesses the reproductive function, asking about family traditions assesses the socialization function, and checking the environment assesses the physical function CHAPTER 4 Health of the Individual, Family, and Community

7.A registered nurse assumes the role of nurse coach to provide teaching to patients who are recovering from a stroke. Which nursing intervention directly relates to this role? The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. The nurse becomes a mentor to the patients and encourages them to create their own fitness programs. The nurse assumes an authoritative role to design the structure of the coaching session and support the achievement of patient goals.

✅a. A nurse coach establishes a partnership with a patient and, using discovery, facilitates the identification of the patient's personal goals and agenda to lead to change rather than using teaching and education strategies with the nurse as the expert. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session, supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals. CHAPTER 9 Teaching and Counseling

5.A nurse is preparing to teach a patient with asthma how to use his inhaler. Which teaching method would be the BEST choice to teach the patient this skill? Demonstration Lecture Discovery Panel session

✅a. Demonstration of techniques, procedures, exercises, and the use of special equipment is an effective patient-teaching strategy for a skill. Lecture can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruction, except in combination with other strategies. Discovery is a good method for teaching problem-solving techniques and independent thinking. Panel discussions can be used to impart factual material but are also effective for sharing experiences and emotions CHAPTER 9 Teaching and Counseling

10.A nurse working in a long-term care facility personally follows accepted guidelines for a healthy lifestyle. How does this nurse promote health in the residents of this facility? A. By being a role model for healthy behaviors B. By not requiring sick days from work C. By never exposing others to any type of illness D. By budgeting time and resources efficiently

✅a. Good personal health enables the nurse to serve as a role model for patients and families. CHAPTER 3 Health, Wellness, and Health Disparities

6. An older nurse asks a younger coworker why the new generation of nurses just aren't ethical anymore. Which reply reflects the BEST understanding of moral development? A. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." B. "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" C. "Ethics is genetically determined...it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." D. "I agree! It's impossible to be ethical when working in a practice setting like this!"

✅a. The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually. CHAPTER 6 Values, Ethics, and Advocacy

9. A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias? A. Cultural imposition B. Clustering C. Cultural competency D. Stereotyping

✅a. The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years. CHAPTER 5 Cultural Diversity

2. A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? A. "New mothers need support." B. "The lack of a father is difficult." C. "How are you today?" D. "It is a very sad situation."

✅a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles. CHAPTER 8 Communication

7.An attorney is representing a patient's family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse's actions. How should the nurse respond? A. "I'm sorry, but I can't talk with you; you will have to contact my attorney." B. "I will answer your questions so you'll understand how the situation occurred." C. "I hope I won't be blamed for the death because it was so busy that day." D. "First tell me why you are doing this to me. This could ruin my career!"

✅a. The nurse should not discuss the case with anyone at the facility (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters. This is one of the cardinal rules for nurse defendants. CHAPTER 7 Legal Dimensions of Nursing Practice

8. A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse's commitment to the principle of autonomy? A. The nurse helps the patient prepare a durable power of attorney document. B. The nurse gives the patient undivided attention when listening to concerns. C. The nurse keeps a promise to provide a counselor for the patient. D. The nurse competently administers pain medication to the patient.

✅a. The principle of autonomy obligates nurses to provide the information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients. CHAPTER 6 Values, Ethics, and Advocacy

6. A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? A. Determining the progress made in achieving established goals B. Clarifying when the patient should take medications Reporting the progress made in teaching to the staff D. Including all family members in the teaching session

✅a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care. CHAPTER 8 Communication

5. The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? A. Cultural assimilation B. Cultural imposition C. Culture shock D. Ethnocentrism

✅a. When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different in a process called assimilation. Cultural imposition occurs when one person believes that everyone should conform to his or her own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups. CHAPTER 5 Cultural Diversity

6. A nurse states, "That patient is 78 years old—too old to learn how to change a dressing." What is the nurse demonstrating? A. Cultural imposition B. Clustering C. Cultural competency D. Stereotyping

1. A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe this process? Select all that apply. People are born with values. Values act as standards to guide behavior. Values are ranked on a continuum of importance. Values influence beliefs about health and illness. Value systems are not related to personal codes of conduct. Nurses should not let their values influence patient care.

✅b, c, d. A value is a belief about the worth of something, about what matters, which acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person's values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture. CHAPTER 6 Values, Ethics, and Advocacy

3. A nurse is using general systems theory to describe the role of nursing to provide health promotion and patient teaching. Which statements reflect key points of this theory? Select all that apply. A. A system is a set of individual elements that rarely interact with each other. B. The whole system is always greater than the sum of its parts. C. Boundaries separate systems from each other and their environments. D. A change in one subsystem will not affect other subsystems. E. To survive, open systems maintain balance through feedback. F. A closed system allows input from or output to the environment

✅b, c, e. According to general systems theory, a system is a set of interacting elements contributing to the overall goal of the system. The whole system is always greater than its parts. Boundaries separate systems from each other and their environments. Systems are hierarchical in nature and are composed of interrelated subsystems that work together in such a way that a change in one element could affect other subsystems, as well as the whole. To survive, open systems maintain balance through feedback. An open system allows energy, matter, and information to move freely between systems and boundaries, whereas a closed system does not allow input from or output to the environment. a. Madeline L CHAPTER 2 Theory, Research, and Evidence-Based Practice

9. A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply. A. An incident report is used as disciplinary action against staff members. B. An incident report is used as a means of identifying risks. C. An incident report is used for quality control. The facility manager completes the incident report. D. An incident report makes facts available in case litigation occurs. E. Filing of an incident report should be documented in the patient record.

✅b, c, e. Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs; in some states, incident reports may be used in court as evidence. A health care provider completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed. CHAPTER 7 Legal Dimensions of Nursing Practice

7. Nurses perform health promotion activities at a primary, secondary, or tertiary level. Which nursing actions are considered tertiary health promotion? Select all that apply. A. A nurse runs an immunization clinic in the inner city. B. A nurse teaches a patient with an amputation how to care for the residual limb. C. A nurse provides range-of-motion exercises for a paralyzed patient. D. A nurse teaches parents of toddlers how to childproof their homes. E. A school nurse provides screening for scoliosis for the students. F. A nurse teaches new parents how to choose and use an infant car seat.

✅b, c. Tertiary health promotion and disease prevention begins after an illness is diagnosed and treated to reduce disability and to help rehabilitate patients to a maximum level of functioning. These activities include providing ROM exercises and patient teaching for residual limb care. Providing immunizations and teaching parents how to childproof their homes and use an appropriate car seat are primary health promotion activities. Providing screenings is a secondary health promotion activity. CHAPTER 3 Health, Wellness, and Health Disparities

4. A nurse is planning teaching strategies based on the affective domain of learning for patients addicted to alcohol. What are examples of teaching methods and learning activities promoting behaviors in this domain? Select all that apply. The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. The nurse reinforces the mental benefits of gaining self-control over an addiction.

✅b, d, f. Affective learning includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence to be able to give up drinking). Cognitive learning involves the storing and recalling of new knowledge in the brain, such as the learning that occurs during a lecture or by using a pamphlet for teaching. Learning a physical skill involving the integration of mental and muscular activity is called psychomotor learning, which may involve a return demonstration of a skill. CHAPTER 9 Teaching and Counseling

2. The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of nursing interventions help meet physiologic needs? Select all that apply. A. Preventing falls in the facility B. Changing a patient's oxygen tank C. Providing materials for a patient who likes to draw D. Helping a patient eat his dinner E. Facilitating a visit from a spouse F. Referring a patient to a cancer support group

✅b, d. Physiologic needs—oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. Providing food and oxygen are examples of interventions to meet these needs. Preventing falls helps meet safety and security needs; providing art supplies may help meet self-actualization needs; facilitating visits from loved ones helps meet self-esteem needs; and referring a patient to a support group helps meet love and belonging needs. CHAPTER 4 Health of the Individual, Family, and Community

1. A nurse working in a primary care facility assesses patients who are experiencing various levels of health and illness. Which statements define these two concepts? Select all that apply. A. Health and illness are the same for all people. B. Health and illness are individually defined by each person. C. People with acute illnesses are actually healthy. D. People with chronic illnesses have poor health beliefs. E. Health is more than the absence of illness. F. Illness is the response of a person to a disease.

✅b, e, f. Each person defines health and illness individually, based on a number of factors. Health is more than just the absence of illness; it is an active process in which a person moves toward his or her maximum potential. An illness is the response of the person to a disease. CHAPTER 3 Health, Wellness, and Health Disparities

3. A nurse who is working in a hospital setting uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. A. A patient decides to quit smoking following a diagnosis of lung cancer. B. A patient shows off a new outfit that she is wearing after losing 20 pounds. C. A patient chooses to work fewer hours following a stress-related myocardial infarction. D. A patient incorporates a new low-cholesterol diet into his daily routine. E. A patient joins a gym and schedules classes throughout the year. F. A patient proudly displays his certificate for completing a marathon.

✅b, f. Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts on the value by combining choice and behavior with consistency and regularity, such as joining a gym for the year and following a low-cholesterol diet faithfully. CHAPTER 6 Values, Ethics, and Advocacy

5. Review of a patient's record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed? A. Assault B. Battery C. Invasion of privacy D.False imprisonment

✅b. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment. CHAPTER 7 Legal Dimensions of Nursing Practice

9. A nurse is caring for a patient who is admitted to the hospital with injuries sustained in a motor vehicle accident. While he is in the hospital, his wife tells him that the bottom level of their house flooded, damaging their belongings. When the nurse enters his room, she notes that the patient is visibly upset. The nurse is aware that the patient will most likely be in need of which type of counseling? Long-term developmental Short-term situational Short-term motivational Long-term motivational

✅b. Short-term counseling might be used during a situational crisis, which occurs when a patient faces an event or situation that causes a disruption in life, such as a flood. Long-term counseling extends over a prolonged period; a patient experiencing a developmental crisis, for example, might need long-term counseling. Motivational interviewing is an evidence-based counseling approach that involves discussing feelings and incentives with the patient. A caring nurse can motivate patients to become interested in promoting their own health. CHAPTER 9 Teaching and Counseling

5. A patient in a community health clinic tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the patient exhibiting? A. Stage 1: Experiencing symptoms B. Stage 2: Assuming the sick role C. Stage 3: Assuming a dependent role D. Stage 4: Achieving recovery and rehabilitation

✅b. Stage 2: Assuming the sick role. When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities. In stage 1: Experiencing symptoms, the first indication of an illness usually is recognizing one or more symptoms that are incompatible with one's personal definition of health. The stage of assuming a dependent role is characterized by the patient's decision to accept the diagnosis and follow the prescribed treatment plan. In the achieving recovery and rehabilitation role, the person gives up the dependent role and resumes normal activities and responsibilities. CHAPTER 3 Health, Wellness, and Health Disparities

10.A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? A. Students are not responsible for their acts of negligence resulting in patient injury. B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. C. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

✅b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student's competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance. CHAPTER 7 Legal Dimensions of Nursing Practice

5. A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute? A. Providing honest information to patients and the public B. Promoting universal access to health care C. Planning care in partnership with patients D. Documenting care accurately and honestly

✅b. The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honestly are examples of integrity, and planning care in partnership with patients is an example of autonomy. CHAPTER 6 Values, Ethics, and Advocacy

4. A nurse is using the ESFT model to understand a patient's conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model—Explanatory model of health and illness? A. How do you get your medications? B. How does having COPD affect your lifestyle? C. Are you concerned about the side effects of your medications? D. Can you describe how you will take your medications?

✅b. The ESFT model guides providers in understanding a patient's explanatory model (a patient's conception of her or his illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches. Asking the questions: "How does having COPD affect your lifestyle?" explores the explanatory model, "How do you get your medications?" refers to the social and environmental factor, "Are you concerned about the side effects of your medications?" addresses fears and concerns, and "Can you describe how you will take your medications?" involves therapeutic contracting. CHAPTER 5 Cultural Diversity

7. A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention? A. Use short words and talk more loudly. B. Ask an interpreter for help. C. Explain why care can't be provided D. Provide instructions in writing.

✅b. The nurse should ask an interpreter for help. Many facilities have a qualified interpreter who understands the health care system and can reliably provide assistance. Using short words, talking loudly, and providing instructions in writing will not help the nurse communicate with this patient. Explaining why care can't be provided is not an acceptable choice because the nurse is required to provide care; also, since the patient doesn't speak English, she won't understand what the nurse is saying.. CHAPTER 5 Cultural Diversity

12.A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? A. A closed-ended answer B. Information clarification C. The nurse to give advice D. Assertive behavior

✅b. The patient's question allows the nurse to clarify information that is new to the patient or that requires further explanation. CHAPTER 8 Communication

2. A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

✅c, d, e. Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information. School-aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible; they are also open to new learning experiences but need learning to be reinforced by either a parent or health care provider as they become more involved with their friends and school activities. Teaching strategies designed for an adolescent patient should recognize the adolescent's need for independence, as well as the need to establish a trusting relationship that demonstrates respect for the adolescent's opinions. CHAPTER 9 Teaching and Counseling

15.During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. A. Fill the silence with lighter conversation directed at the patient. B. Use the time to perform the care that is needed uninterrupted. C. Discuss the silence with the patient to ascertain its meaning. D. Allow the patient time to think and explore inner thoughts. E. Determine if the patient's culture requires pauses between conversation. F. Arrange for a counselor to help the patient cope with emotional issues.

✅c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor. CHAPTER 8 Communication

8. A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive? A. "Do you think you will be able to eat the food we have here?" B. "Do you understand that we can't prepare special meals?" C. "What types of food do you eat for meals?" D. "Why can't you just eat our food while you are here?"

✅c. Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive. CHAPTER 5 Cultural Diversity

4. A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? A. Accreditation B. Licensure C. Certification D.Board approval

✅c. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing. CHAPTER 7 Legal Dimensions of Nursing Practice

4. A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating? A.Tertiary B. Secondary C. Primary D. Promotive

✅c. Giving influenza injections is an example of primary health promotion and illness prevention. CHAPTER 3 Health, Wellness, and Health Disparities

10. A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care? A. Learning the predominant language of the community B. Obtaining significant information about the community C. Treating each patient at the clinic as an individual D. Recognizing the importance of the patient's family

✅c. In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care. This basic objective can be accomplished by learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life. CHAPTER 5 Cultural Diversity

3. A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. What is the term for those bringing the charges against the nurse? A. Appellates B. Defendants C. Plaintiffs D. Attorneys

✅c. The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant. CHAPTER 7 Legal Dimensions of Nursing Practice

6. Based on the components of the physical human dimension, the nurse would expect which clinic patient to be most likely to have annual breast examinations and mammograms? A. Jane, whose best friend had a benign breast lump removed B. Sarah, who lives in a low-income neighborhood C. Tricia, who has a family history of breast cancer D. Nancy, whose family encourages regular physical examinations

✅c. The physical dimension includes genetic inheritance, age, developmental level, race, and biological sex. These components strongly influence the person's health status and health practices. A family history of breast cancer is a major risk factor. CHAPTER 3 Health, Wellness, and Health Disparities

9. A nurse incorporates concepts from current models of health when providing health promotion classes for patients. What is a key concept of both the health-illness continuum and the high-level wellness models? A. Illness as a fixed point in time B. The importance of family C. Wellness as a passive state D. Health as a constantly changing state

✅d. Both these models view health as a dynamic (constantly changing state). CHAPTER 3 Health, Wellness, and Health Disparities

1. A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? A. Public law B. Private law C. Civil law D. Criminal law

✅d. Criminal law concerns state and federal criminal statutes, which define criminal actions such as murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry. CHAPTER 7 Legal Dimensions of Nursing Practice

6. A veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? A. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. B. The fact that this patient should not have died since she was a healthy grandmother of 10, who was physically active and involved in her community. C. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome of routine hernia surgery. D. The nurse had a duty to monitor the patient's vital signs, and due to the nurse's failure to perform this duty in this circumstance, the patient died.

✅d. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient. CHAPTER 7 Legal Dimensions of Nursing Practice

8.A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? A. The nurse is not responsible, because the nurse was following the doctor's orders. B. Only the nurse is responsible, because the nurse actually administered the medication. C. Only the health care provider is responsible, because the health care provider actually ordered the drug. D. Both the nurse and the health care provider are responsible for their respective actions.

✅d. Nurses are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. If the nurse should have anticipated injury and did not, both the prescribing health care provider and the administering nurse are responsible for the harms to which they contributed. CHAPTER 7 Legal Dimensions of Nursing Practice

14.A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? A. "Do you take two injections of insulin to decrease the complications?" B. "Most health care providers recommend diet and exercise to regulate blood sugar." C. "Most complications of diabetes are related to neuropathy." D. "What specific complications have you experienced?"

✅d. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques. CHAPTER 8 Communication

4. A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? A. Altruism B. Autonomy C. Human dignity D. Integrity

✅d. The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations. CHAPTER 6 Values, Ethics, and Advocacy

8. A nurse working in an "Aging in Place" facility interviews a married couple in their late seventies. Based on Duvall's Developmental Tasks of Families, which developmental task would the nurse assess for this couple? A. Maintenance of a supportive home base B. Strength of the marital relationship C. Ability to cope with loss of energy and privacy D. Adjustment to retirement years

✅d. The developmental tasks of the family with older adults are to adjust to retirement and possibly to adjust to the loss of a spouse and loss of independent living. Maintaining a supportive home base and strengthening marital relationships are tasks of the family with adolescents and young adults. Coping with loss of energy and privacy is a task of the family with children. CHAPTER 4 Health of the Individual, Family, and Community

4. A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? A. "I'm just the IV therapist checking your IV." B. "I've been transferred to this division and will be caring for you." C. "I'm sorry, my name is John Smith and I am your nurse." D. "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

✅d. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient. CHAPTER 8 Communication

3. A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? A. The use of reflective questions B. The use of closed questions C. The use of assertive questions D. The use of clarifying questions

✅d. The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication. CHAPTER 8 Communication

5. A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? A. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." B. The nurse places a hand on the patient's arm and states, "You feel so alone." C. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." D. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

✅d. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely. CHAPTER 8 Communication

8.A nurse is counseling a 19-year-old athlete who had his right leg amputated below the knee following a motorcycle accident. During the rehabilitation process, the patient refuses to eat or get up to ambulate on his own. He says to the nurse, "What's the point. My life is over now and I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response to this patient? "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." "You should concentrate on other sports that you could play even with prosthesis." "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

✅d. This answer communicates respect and sensitivity to the patient's needs and offers an opportunity to discuss his feelings with the nurse or another health care professional. The other answers do not allow the patient to express his feelings and receive the counseling he needs. CHAPTER 9 Teaching and Counseling

2. A pediatric nurse is assessing a 5-year-old boy who has dietary modifications related to his diabetes. His parents tell the nurse that they want him to value good nutritional habits, so they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? Modeling Moralizing Laissez-faire Rewarding and punishing

✅d. When rewarding and punishing are used to transmit values, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Through modeling, children learn what is of high or low value by observing parents, peers, and significant others. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Those who use the laissez-faire approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system. CHAPTER 6 Values, Ethics, and Advocacy

7. A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse's action reflects which principle of bioethics? A. Autonomy B. Beneficence C. Justice D. Fidelity E. Nonmaleficence

✅e. Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another's right to make decisions, beneficence obligates us to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises. CHAPTER 6 Values, Ethics, and Advocacy

Conflict Resolution Strategies

❑Avoiding: There is awareness of the conflict situation, but the parties involved decide to either ignore the conflict, or avoid, or postpone its resolution. The conflict has not been resolved and may resurface later in an exaggerated form. ❑Collaborating: This is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. This focus on problem solving is based on mutual respect, honest communication, and shared decision making. ❑Competing: This approach results in a win for one party at the expense of the other group. This win-lose confrontation can leave the loser frustrated, with a desire to "get even" in the future. This strategy may be used when one party has more knowledge regarding the situation, or when resistance is appropriate because of ethical concerns or unsafe patient care practices. ❑Compromising: For this technique to be effective, both parties must be willing to relinquish something of equal value. If that does not occur, either or both parties may feel that they have lost the conflict and given up more than the other group. Cooperating/Accommodating: One party makes a conscious decision to let the other group win and may collect an "IOU" for use in the future. This party's original loss may result in a more positive outcome in the future. Smoothing: Smoothing is an effort to compliment the other party and focus on agreement rather than disagreement, thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique. CHAPTER 10 Leading, Managing, and Delegating

Topics for Health Teaching and Counseling

❑Promoting Health •Developmental and maturational issues •Normal childbearing •Hygiene •Nutrition •Exercise •Mental health •Spiritual health ❑Preventing Illness First aid •Safety •Immunizations •Screening Identification and management of risk factors ❑Restoring Health Orientation to treatment center and staff Patients' and nurses' expectations of one another The illness and physical condition: anatomy and physiology, etiology of problem, significance of symptoms, prognosis The medical and nursing regimens and how the patient can participate in care Self-care practices the patient and family need to manage the patient's condition independently ❑Facilitating Coping How the patient's physical and mental condition affects other areas of functioning; lifestyle counseling Measures that maximize independence and enhance self-concept Stress management Environmental alterations Community resources Appropriate referrals (e.g., physical therapy, occupational therapy, self-help groups, psychiatric-mental health counselor) Grief and bereavement counseling

19 of 19 The nurse is documenting a pain assessment. Which pain descriptions document location of pain? (Select all that apply.) Select all that apply. Localized pain Sharp pain Negative vocalization Radiating pain Referred pain Pain rated as a 4 on a scale of 0-10.

✅Localized pain ✅Radiating pain ✅Referred pain Pain can be described as belonging to one of four categories related to its location: localized, projected, referred, and radiating. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Referred pain is felt in an area distant from the site of painful stimuli. Radiating pain is felt along a specific nerve or nerves. Pain rated as a 4 on a scale of 0-10 describes the intensity of the pain, not the location. Sharp pain describes the quality of the pain, not the location. Negative vocalization is an indicator of the presence of and quality of pain in adults with dementia Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

Following a fall, a 62-year-old client is admitted to the rehabilitation unit with a broken collarbone and a full leg brace. What transfer technique will the nurse use for this client? Cane-assisted transfer Bear-hug technique Mechanical lift Slide board

✅Mechanical lift A mechanical lift is the transfer technique indicated for this client. Mechanical lifts use slings to lift, transfer, move, and reposition immobile clients. Because the client is older and has a broken collarbone and is unable to use both arms to independently transfer safely, a mechanical lift is the best method for moving this client. In the past, nurses and therapists used a bear-hug technique to lift the client from bed to chair and back again. However, because heavy lifting can result in back injury, many facilities have adopted a "no lift" policy and rely on other methods for client transfers. A cane will hinder transfer of the client. Slide boards are typically used for transferring quadriplegic clients. Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

6 of 18 Which condition, when assessed in a client who is dying requires the nurse to take action? Alternating apnea and rapid breathing Cool extremities Moaning Anorexia

✅Moaning Moaning indicates pain and requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the client who is dying. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

11 of 18 A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order will the nurse implement first? Morphine sulfate sublingually as needed Albuterol solution per nebulizer Prednisone elixir 10 mg orally Oxygen 2 to 6 L/min per nasal cannula

✅Morphine sulfate sublingually as needed Morphine sulfate is the standard treatment for the dyspneic client who is near death. Albuterol, oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

16 of 19 A client reports increasing pain during dressing changes to the nurse. Which interventions are recommended for the client? (Select all that apply.) Select all that apply. Music therapy Assistance by the client with the dressing change Epidural analgesic Transcutaneous electrical nerve stimulation (TENS) Distraction Premedication

✅Music therapy ✅Distraction ✅Premedication Interventions recommended for the client include distraction, music therapy, and premedication. Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment. Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain, but its use during a dressing change would not be feasible. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at an increased risk for hypokalemia? Nephrostomy tube to drainage bag Indwelling catheter to gravity Chest tube to water seal NG tube to suction

✅NG tube to suction To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. Hypokalemia refers to a depletion of potassium and can result from a reduction in total potassium stores or from a temporary shift of extracellular potassium into the cell. Reductions in total potassium are caused by medications, such as diuretics, digitalis, and corticosteroids; Cushing's syndrome; diarrhea; vomiting; and wound drainage among others. Reductions in extracellular potassium caused by potassium shifting back into cells result from alkalosis, hyperinsulinism, total parenteral nutrition, and water intoxication among others. Intestinal suctioning through an NG tube results in the loss of gastric fluids. Potassium exists in large amounts in the GI fluids and is lost when gastric fluids are lost. This client is at an increased risk for hypokalemia. Nephrostomy tube to drainage bag To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. A nephrostomy tube drains urine, and although the kidneys filter potassium and can be a source of potassium loss, without a secondary risk factor, such as taking thiazide or loop diuretics, another client would be at greater risk for hypokalemia. Indwelling catheter to gravity To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. An indwelling catheter is inserted in the bladder to drain urine. Although the kidneys filter potassium and can be a source of potassium loss, without a secondary risk factor, such as taking diuretics, another client would be at greater risk for hypokalemia. Chest tube to water seal To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. Chest tubes are used to evacuate air or blood from the pleural space and are not associated with potassium loss; therefore, another client would be at greater risk for hypokalemia. NurseLogic Knowledge and Clinical Judgment Advanced

The nurse is providing health teaching at a health fair about preventing influenza. What adult groups are at risk for contracting this disease due to altered immunity? (Select all that apply.) Select all that apply. Nonimmunized adults Adults who do not practice a healthy lifestyle Adults with substance use disorder Women who are pregnant Older adults Adults with chronic illness

✅Nonimmunized adults ✅Adults who do not practice a healthy lifestyle ✅Adults with substance use disorder ✅Older adults ✅Adults with chronic illness All of these groups have problems with adequate immunity either due to advanced age, illness, substance use, or lack of healthy lifestyle practices. Not being immunized for influenza is also a poor health practice. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

The client is struggling with use of eating utensils. Which rehabilitation team member is brought in to help the client with this problem? Occupational therapist Physical therapist Activity therapist Physiatrist

✅Occupational therapist The occupational therapist is brought in to help the client with the use of eating utensils. The occupational therapist works to develop the client's fine motor skills used for activities of daily living, such as those required for eating, maintaining hygiene, dressing, and driving. The recreational or activity therapist works to help the client continue or develop hobbies or interests. The physiatrist is a physician who specializes in rehabilitative medicine; this rehabilitation team member is not the best resource for this situation. The physical therapist helps the client achieve mobility (e.g., by facilitating ambulation and teaching the client to use a walker). Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

5 of 18 A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention will the nurse implement? Administer intravenous hydration. Call the family to come in right away. Offer ice chips. Bring in the client's favorite food.

✅Offer ice chips. The client who is dying should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth." The client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not currently necessary. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

A client is scheduled to have an ileostomy placed. How does the nurse document this type of surgery? Diagnostic Cosmetic Curative Palliative

✅Palliative Colostomy surgery is categorized as palliative. Palliative surgery is performed to increase the quality of life (and often to reduce pain) while reducing stressors on the body. It is noncurative in nature. Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Question 12 of 13 The nurse provides client-centered care for an older client who was admitted from an assisted living facility. What attributes would the nurse demonstrate when providing care for this client? (Select all that apply.) Select all that apply. Physical comfort Emotional support Client respect Communication and education Care coordination Transition and continuity of care

✅Physical comfort ✅Emotional support ✅Client respect ✅Communication and education ✅Care coordination ✅Transition and continuity of care All of these choices are attributes of client-centered care. Respect for all individuals is especially important. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? Tolerance Pseudoaddiction Physical dependence Addiction

✅Physical dependence The nurse expects the client to have a physical dependence on the opioid. Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms. Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the client's situation. Tolerance is similar to physical dependence, but occurs earlier and consists of a decrease in one or more of the effects of the opioid. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the client's situation Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

15 of 18 A client who is dying cannot swallow and is accumulating audible mucus in the upper airway (death rattles). These noises are upsetting to family members. What nursing action is appropriate? Place the client in a side-lying position so secretions can drain. Use a Yankauer suction tip to remove secretions from the client's upper airway. Position the client in a high-Fowler position to minimize secretions. Assist the family in leaving the room so that they can compose themselves.

✅Place the client in a side-lying position so secretions can drain. Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler position is ineffective in helping the client who has lost the ability to swallow and increases the danger of choking and aspiration. Oropharyngeal suctioning is not recommended for removal of secretions, because it is not effective and may even agitate the client. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

What roles does the rehabilitation nurse have in the functioning of the rehabilitation team? (Select all that apply.) Select all that apply. Plans continuity of care for discharge. Coordinates rehabilitation team activities. Coordinates holistic care. Develops the client's fine motor skills. Retrains clients with swallowing challenges.

✅Plans continuity of care for discharge. ✅Coordinates rehabilitation team activities. ✅Coordinates holistic care. Providing holistic care and coordinating all activities of the rehabilitation team is a role for the rehabilitation nurse—perhaps the primary role. The rehabilitation team is diverse and multi-skilled; getting the right skills and services to the client is a primary role for the rehabilitation nurse. The rehabilitation nurse coordinates the care that the client will continue to receive after discharge; this coordination actually begins as the client is admitted to the rehabilitation unit. Fine motor skill development is the responsibility of specialized members of the rehabilitation team. The rehabilitation nurse may be the one who sees these needs and gets the physical therapist, the occupational therapist, and activity therapist involved. Working with clients who have swallowing difficulties is the responsibility of the speech therapist; this activity would not be a role for the rehabilitation nurse.

Question 11 of 13 Which principal nursing actions best support a focus on client safety? (Select all that apply.) Select all that apply. Respect for others Client restraints Preoperative checklists Handwashing Five rights of drug administration

✅Preoperative checklists ✅Handwashing ✅Five rights of drug administration Handwashing is the number-one way to prevent infection in clients. Checklists can help prevent mistakes in care for a surgical client, thus ensuring a safe environment. Adhering to the five rights of medication administration helps to prevent errors in this important nursing care activity, providing for increased safety in client care. Although restraints may help clients who are confused to keep from hurting themselves, they are potentially risky and are used infrequently because of the harm they can cause. Respect is an important element in client care, but it is not directly tied to the provision of a safe care setting. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program? Watch a video discussing healthy meal preparation. Prepare a healthy meal to serve at the end of class. Read pamphlets about preparing a healthy meal. Discuss healthy meal preparation as a class.

✅Prepare a healthy meal to serve at the end of class. In this item, you need knowledge of learning styles in order to determine strategies that enhance learning for each of the styles. This item requires critical thinking because you need to recall knowledge of each of the learning styles in order to analyze the options and determine which strategy is appropriate to enhance the transfer of knowledge for tactile learners. Learning styles are simply different approaches to learning. For learning to be effective, it is important to identify and recognize learning styles of the clients being taught. Tactile learners learn best by touching and doing; therefore, having the participants prepare a healthy meal to serve at the end of class is a learning strategy appropriate for tactile learners. Watch a video discussing healthy meal preparation. In this item, you need knowledge of learning styles in order to determine strategies that enhance learning for each of the styles. This item requires critical thinking because you need to recall knowledge of each of the learning styles in order to analyze the options and determine which strategy is appropriate to enhance the transfer of knowledge for tactile learners. Learning styles are simply different approaches to learning. For learning to be effective, it is important to identify and recognize learning styles of the clients being taught. Visual learners learn best from strategies that involve sight; therefore, having the participants watch a video discussing healthy meal preparation is a learning strategy appropriate for visual learners. This activity should not be included as a learning strategy for tactile learners. Read pamphlets about preparing a healthy meal. In this item, you need knowledge of learning styles in order to determine strategies that enhance learning for each of the styles. This item requires critical thinking because you need to recall knowledge of each of the learning styles in order to analyze the options and determine which strategy is appropriate to enhance the transfer of knowledge for tactile learners. Learning styles are simply different approaches to learning. For learning to be effective, it is important to identify and recognize learning styles of the clients being taught. Visual learners learn best from strategies that involve sight; therefore, having the participants read pamphlets about preparing a healthy meal is a learning strategy appropriate for visual learners. This activity should not be included as a learning strategy for tactile learners. Discuss healthy meal preparation as a class. In this item, you need knowledge of learning styles in order to determine strategies that enhance learning for each of the styles. This item requires critical thinking because you need to recall knowledge of each of the learning styles in order to analyze the options and determine which strategy is appropriate to enhance the transfer of knowledge for tactile learners. Learning styles are simply different approaches to learning. For learning to be effective, it is important to identify and recognize learning styles of the clients being taught. Auditory learners learn best from strategies that involve hearing; therefore, having the participants discuss healthy meal preparation as a class is a learning strategy appropriate for auditory learners. This activity should not be included as a learning strategy for tactile learners.

Question 9 of 15 The nurse is comparing the clinical judgment measurement model (CJMM) and the nursing process. Which step of the CJMM is specific to analysis? Generate solutions Take actions Recognize cues Prioritize hypothesis

✅Prioritize hypothesis The step of the CJMM that correlates with analysis in the nursing process is to prioritize hypothesis. Also, within this step is analyzing cues. Recognizing cues is assessment, generating solutions is planning, and taking action is implementation. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

The nurse completes the preoperative checklist for a client scheduled for general surgery. Which factor does the nurse identify that places the client at high risk for the planned procedure? (Select all that apply.) Select all that apply. Ten pounds (4.5 kg) over ideal body weight Takes saw palmetto for benign prostatic hyperplasia (BPH) Anesthesia complications experienced by partner Currently prescribed methylprednisolone therapy Age 59 years History of diabetes mellitus

✅Takes saw palmetto for benign prostatic hyperplasia (BPH) ✅Currently prescribed methylprednisolone therapy ✅History of diabetes mellitus The client's risk factors include diabetes mellitus, being on methylprednisolone therapy, and taking an herbal preparation (saw palmetto). Diabetes contributes an increased risk for surgery or postsurgical complications. Methylprednisolone use can decrease the body's ability to fight infection. Any type of herbal preparation has the potential to interfere with anesthesia or recovery. Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but not anesthesia complications experienced by a partner. Obesity increases the risk for poor wound healing, but being 10 lb (4.5 kg) overweight does not categorize this client as obese. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

14 of 18 A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? Explains to the family that aspiration may be a concern. Administers nutrition and fluids through a nasogastric tube. Teaches the family how to provide oral care. Obtains a physician order to initiate an IV line.

✅Teaches the family how to provide oral care. Because the oral mucosa will become dry, the initial action taken by the nurse would be to teach the family members how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

Question 15 of 15 The nurse is teaching a class on systems thinking in nursing. What teaching will the nurse include? (Select all that apply.) Select all that apply. Systems thinking is not affected by health policy at the national level. The complexity of client care can affect systems thinking. Systems thinking shifts the focus from safety to quality in care. It is important for the nurse to place all focus on individualized client care . Systems thinking allows the nurse to assess the root of problems. Interprofessional, collaborative care is fostered when using systems thinking.

✅The complexity of client care can affect systems thinking. ✅Systems thinking allows the nurse to assess the root of problems. ✅Interprofessional, collaborative care is fostered when using systems thinking. Systems thinking pushes the nurse to look beyond the individualized client to consider the impacts within the health care system as a whole. Systems thinking does allow the nurse to consider the root problems that affect care and fosters interprofessional care. Systems thinking does not shift away from safety, rather it promotes safety through quality-based care. The complexity of care and health policy as local, state, national, and global levels can affect systems thinking. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

The nurse is caring for a client who has delirium. Which statement is correct regarding this health problem? The focus of managing delirium is to treat the cause. Delirium takes months to years to develop. The cause of delirium is not known. Validation therapy is the best approach for delirium.

✅The focus of managing delirium is to treat the cause. Delirium is an acute confusional state which usually has a specific cause, such as drug therapy, surgery, relocation, and so forth. The focus of managing this problem is to remove or treat the causative factor(s). The other choices are correct about dementia, a chronic confusional state. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

16 of 18 In which newly admitted client situations does the nurse initiate a conversation about advance directives? (Select all that apply.) Select all that apply. The laboring mother expecting her first child A client with a non-life-threatening illness A person who currently has advance directives The comatose client who was injured in an automobile crash The client with end-stage kidney disease

✅The laboring mother expecting her first child ✅A client with a non-life-threatening illness ✅Place the client in a side-lying position so secretions can drain. ✅The client with end-stage kidney disease All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with preexisting advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients who have potentially life-threatening diseases or conditions should establish advance directives while they are able to do so. The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

Question 10 of 13 Which of these hospital staff members will the nurse manager request to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury? The primary health care provider assigned as the client's medical resident The physical therapist who developed the client's exercise program The nurse responsible for the client's case management The unit-based RN who has cared for the client during the hospital stay

✅The nurse responsible for the client's case management The case manager role includes coordination of acute care and postdischarge community services for the client. The physical therapist, health care provider, and unit-based RN will have input into planning for rehabilitation for the client, but are not the best choice to coordinate a smooth transition from acute care to community rehabilitation services The primary health care provider assigned as the client's medical resident The case manager role includes coordination of acute care and postdischarge community services for the client. The physical therapist, health care provider, and unit-based RN will have input into planning for rehabilitation for the client, but are not the best choice to coordinate a smooth transition from acute care to community rehabilitation services. The physical therapist who developed the client's exercise program The case manager role includes coordination of acute care and postdischarge community services for the client. The physical therapist, health care provider, and unit-based RN will have input into planning for rehabilitation for the client, but are not the best choice to coordinate a smooth transition from acute care to community rehabilitation services. . The unit-based RN who has cared for the client during the hospital stay The case manager role includes coordination of acute care and postdischarge community services for the client. The physical therapist, health care provider, and unit-based RN will have input into planning for rehabilitation for the client, but are not the best choice to coordinate a smooth transition from acute care to community rehabilitation services. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective? Toast with peanut butter Apple juice Yogurt with fresh fruit Beef broth

✅Toast with peanut butter In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and manifests as a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations. Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some foods and includes others as appropriate food choices reduces the occurrence and severity of dumping syndrome. Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome. Apple juice In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Beverages with high sugar content, such as apple juice, lead to rapid gastric emptying because of high osmolarity and should be avoided. Yogurt with fresh fruit In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Dairy products and sugars, such as yogurt with fresh fruit, lead to rapid gastric emptying because of high osmolarity and should be avoided. Beef broth MY ANSWER In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Salty foods, such as broths, lead to rapid gastric emptying because of high osmolarity and should be avoided. NurseLogic Knowledge and Clinical Judgment Advanced

A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries? Twisting at the waist and shoulders Standing with feet in a wide stance Positioning self close to the client Using arms and legs to lift

✅Twisting at the waist and shoulders In this item, you need nursing knowledge related to body mechanics. Based on an understanding of this concept, you can identify which option describes an action by the nurse that does not reflect good body mechanics. This is a negatively worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the use of appropriate body mechanics. To prevent a lift injury when transferring the client from the bed to a chair, alignment of the back, neck, pelvis, and feet should be maintained to reduce the risk of injury to the lumbar vertebrae. This action by the newly licensed nurse is not appropriate and indicates a need for additional teaching. Standing with feet in a wide stance In this item, you need nursing knowledge related to body mechanics. Based on an understanding of this concept, you can identify which option describes an action by the nurse that does not reflect good body mechanics. This is a negatively worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the use of appropriate body mechanics. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand with the feet in a wide stance because it improves stability. This action by the newly licensed nurse is appropriate and does not indicate a need for additional teaching. Positioning self close to the client In this item, you need nursing knowledge related to body mechanics. Based on an understanding of this concept, you can identify which option describes an action by the nurse that does not reflect good body mechanics. This is a negatively worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the use of appropriate body mechanics. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client to reduce stress on the back by decreasing the need to reach for the client. This action by the newly licensed nurse is appropriate and does not indicate a need for additional teaching. Using arms and legs to lift In this item, you need nursing knowledge related to body mechanics. Based on an understanding of this concept, you can identify which option describes an action by the nurse that does not reflect good body mechanics. This is a negatively worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the use of appropriate body mechanics. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should use the arms and legs to lift because larger muscle groups allow for heavier lifting without causing injury. This action by the newly licensed nurse is appropriate and does not indicate a need for additional teaching. NurseLogic Knowledge and Clinical Judgment Beginner

19 of 19 The nurse is caring for an adult client who has been prescribed quetiapine last year for bipolar disorder. For which adverse drug effects would the nurse observe? (Select all that apply.) Select all that apply. Urinary retention Hypoglycemia Restlessness Hypertension Parkinsonism

✅Urinary retention ✅Restlessness ✅Parkinsonism The nurse would observe for these adverse effects, as well as hypotension and hyperglycemia. The nurse would observe for these adverse effects, as well as hypotension and hyperglycemia. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication? Urinary retention Rapid respirations Dilated pupils Diarrhea

✅Urinary retention In this item, you need nursing knowledge related to morphine to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of morphine. Morphine is an opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of well-being, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Urinary retention is an adverse effect of morphine. By increasing bladder sphincter and detrusor muscle tone and reducing awareness of bladder stimuli, morphine can cause urinary hesitancy, urinary retention, and urinary urgency. Rapid respirations In this item, you need nursing knowledge related to morphine to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of morphine. Morphine is an opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of well-being, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Rapid respirations are not an adverse effect of morphine. Instead, by reducing the respiratory center's response to carbon dioxide, respiratory depression is an adverse effect of morphine. Dilated pupils In this item, you need nursing knowledge related to morphine to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of morphine. Morphine is an opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of well-being, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Dilated pupils are not an adverse effect of morphine. Instead, morphine can cause pupils to constrict, known as miosis, which can result in impaired vision. Diarrhea In this item, you need nursing knowledge related to morphine to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of morphine. Morphine is an opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of well-being, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Diarrhea is not an adverse effect of morphine. Instead, by decreasing GI motility, constipation is an adverse effect of morphine. NurseLogic Knowledge and Clinical Judgment Beginner

A client who had a hip replacement 2 days ago, reports having pain rated as a 7 on a pain scale of 0-10. What nursing intervention is the highest priority? Teaching key points of the relaxation response Incorporating activities of daily living as soon as possible Encouraging diversional activities Using preemptive analgesia

✅Using preemptive analgesia The nursing intervention with the highest priority in the client's care plan is the use of preemptive analgesia. This technique is designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay. Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the client to perform activities of daily living is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

The hospital nurse is assigned to establish a rehabilitation milieu on the unit. What elements will the nurse include? (Select all that apply.) Select all that apply. Protecting clients from embarrassment (e.g., bowel training) Making the inpatient unit a more homelike environment Allowing time for clients to practice self-management skills Keeping to a structured hospital schedule (e.g., medication administration) Carefully monitoring fluid and dietary intake Encouraging clients and providing emotional support

✅Protecting clients from embarrassment (e.g., bowel training) ✅Making the inpatient unit a more homelike environment ✅Allowing time for clients to practice self-management skills ✅Encouraging clients and providing emotional support As clients undergo rehabilitation, they must learn skills to function independently after they are discharged. Incorporating self-management skills in the environment is crucial. Rehabilitation nurses in hospital settings must provide an environment that encourages and supports clients who are undergoing rehabilitative efforts. The rehabilitative milieu needs to be less structured and more homelike for the client to begin to develop the skills and behaviors that will be needed after discharge. Along with the homelike environment, clients need to be protected from embarrassing situations in this milieu. Although keeping a structured schedule and monitoring fluid and dietary intake are important in the inpatient setting, they are less a matter of focus in the rehabilitation environment. They would not be a primary concern in establishment of this milieu.

The nurse is caring for a client who was bitten by a spider and has cellulitis. What signs and symptoms would the nurse expect? Select all that apply. Redness Discomfort Necrosis Warmth Swelling

✅Redness ✅Discomfort ✅Warmth ✅Swelling Cellulitis is an inflammation of skin and underlying tissues. The cardinal signs and symptoms of inflammation are redness, warmth, swelling, and discomfort or pain.

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse to contact the surgeon? Sanguineous drainage at the suture site Crusting along the incision line Serosanguineous drainage on the dressing Redness and swelling around the incision

✅Redness and swelling around the incision The nurse's concern is redness and swelling around the incision. This needs to be reported to the surgeon because these signs could indicate an infection. Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? Chill formula prior to administration. Verify feeding tube placement. Reduce the rate of the feedings. Place the client supine during feedings

✅Reduce the rate of the feedings. In this item, you need nursing knowledge of how to administer enteral tube feedings, complications of enteral tube feedings, and appropriate nursing actions in the event of those complications. Based on an understanding of these concepts, you can identify which option describes an intervention the nurse should implement for a client who is receiving enteral tube feedings and has diarrhea. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Reducing the rate of feedings is an appropriate action by the nurse to prevent diarrhea after subsequent feedings. A client receiving intermittent enteral tube feedings can experience diarrhea because of the administration of hyperosmolar enteral feedings. To prevent this, administration should be slowed or switched to continuous enteral feedings. Chill formula prior to administration. In this item, you need nursing knowledge of how to administer enteral tube feedings, complications of enteral tube feedings, and appropriate nursing actions in the event of those complications. Based on an understanding of these concepts, you can identify which option describes an intervention the nurse should implement for a client who is receiving enteral tube feedings and has diarrhea. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Chilling the formula prior to administration is not an appropriate action by the nurse to prevent diarrhea after subsequent feedings. Chilled formula can cause abdominal cramping, nausea, and vomiting; therefore, formula should be administered at room temperature. Verify feeding tube placement. In this item, you need nursing knowledge of how to administer enteral tube feedings, complications of enteral tube feedings, and appropriate nursing actions in the event of those complications. Based on an understanding of these concepts, you can identify which option describes an intervention the nurse should implement for a client who is receiving enteral tube feedings and has diarrhea. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Verifying tube placement is not an appropriate action by the nurse to prevent diarrhea after subsequent feedings. While it is good practice to verify placement, a displaced tube will not cause diarrhea. Findings associated with tube displacement include coughing, vomiting, and pulmonary aspiration. Place the client supine during feedings. In this item, you need nursing knowledge of how to administer enteral tube feedings, complications of enteral tube feedings, and appropriate nursing actions in the event of those complications. Based on an understanding of these concepts, you can identify which option describes an intervention the nurse should implement for a client who is receiving enteral tube feedings and has diarrhea. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Placing the client supine during feedings is not an appropriate action by the nurse to prevent diarrhea after subsequent feedings. The head of the bed should be elevated to at least 30° during the administration of enteral tube feedings to prevent aspiration.

Which intervention does the rehabilitation nurse delegate to assistive personnel (AP) who is caring for a 70-year-old client with right-sided weakness following a stroke? Arrange for family members to participate in planning for discharge. Teach the client to use an extended shoehorn when putting on shoes. Reinforce the client's placing the right arm in the sleeve first when dressing. Determine whether the client's passive range-of-motion (ROM) exercises should be increased.

✅Reinforce the client's placing the right arm in the sleeve first when dressing. The assistive personnel (AP) is appropriate to perform the intervention of reinforcing the client's placing the right arm in the sleeve first when dressing. Reinforcement of skills that have been taught by the occupational therapist or nurse is an action that should be done by all caregivers who are involved in the client's care. Planning for discharge, assessing passive ROM exercises, and teaching the use of a shoehorn require broader education and scope of practice and should be done by a licensed staff member such as the RN. Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

An older adult client with end-stage lung cancer and metastasis to the brain has been admitted to the hospital. After trying all options to provide a safe environment, the nursing staff has to apply restraints. Which nursing intervention is required for this client? Using chemical sedation instead of restraints Releasing the restraints at least every 2 hours Checking the restraints every 1 to 2 hours Using the most restrictive devices to prevent falls

✅Releasing the restraints at least every 2 hours The Joint Commission recommends releasing restraints every 2 hours for client care such as turning, repositioning, and toileting. The restraints must be checked every 30 to 60 minutes and not every 1 to 2 hours. Chemical sedation is also considered a restraint. The least restrictive devices should be used. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

A client with lower motor neuron spinal cord dysfunction has not voided, and a bladder scan shows 700 mL of urine in the bladder. Using the client's bladder training plan, what action does the staff RN advise a new graduate nurse to take first with this client? Remind the client to try the Valsalva maneuver. Insert a straight catheter to empty the bladder. Reassess the client's bladder volume in 2 hours. Administer a dose of oxybutynin chloride (Ditropan).

✅Remind the client to try the Valsalva maneuver. The RN advises the new graduate nurse to first try the Valsalva maneuver. Clients with lower motor neuron problems have a flaccid bladder. Increasing pressure on the bladder with the Valsalva maneuver may help the client void. Oxybutynin chloride (Ditropan) is useful in mild cases of overactive bladder. If the Valsalva maneuver is ineffective, straight catheterization may be used to empty the bladder. Because the bladder already holds 700 mL, the nurse should not wait for 2 more hours before taking action to empty the bladder.

The nurse is caring for a client who is immobile. The client is most at risk to develop which complication? Hypertension Muscle hypertrophy Diarrhea Renal calculi

✅Renal calculi Immobility can cause urinary stasis and the development of urinary or renal calculi. Decreased mobility or total immobility for several days can cause serious and often life-threatening complications affecting every body system.Immobility slows gastric motility causing constipation, not increasing it to result in diarrhea. Immobility also does not cause hypertension. Immobility causes muscle atrophy, not hypertrophy. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

53. The client has a severe anaphylactic reaction to insect bites. Which priority discharge intervention should the nurse discuss with the client? 1. Wear an insect repellent on exposed skin. 2. Keep prescribed antihistamines on their person. 3. Keep an EpiPen in the refrigerator at all times. 4. Wear a MedicAlert identification bracelet.

. 1. Wearing insect repellent is an appropriate intervention, but if the client has an insect bite, the repellent will not help prevent anaphylaxis; therefore, this is not the pri- ority intervention. 2. Antihistamines are used in clients with anaphylaxis, but it takes at least 30 min- utes for the medication to work, and if the client has an insect bite, it is not the prior- ity medication. 3. Clients with documented severe anaphy- laxis should carry an EpiPen, which is a prescribed epinephrine injectable device that clients can administer to themselves in case of an insect bite. Keeping the medication in the refrigerator does not allow it to be available to the client at all times. ✅4. The client should wear an identification bracelet because even if the client uses insect repellent, a sting could occur. The bracelet indicates the client is at risk for an anaphylactic reaction; there- fore, this is the priority intervention Comprehensive Examination. Pharmacology Success

15. The elderly client diagnosed with coronary artery disease has been taking aspirin daily for more than a year. Which data warrants notifying the health-care provider? 1. The client has lost 5 pounds in the past month. 2. The client has trouble hearing low tones. 3. The client reports having a funny taste in the mouth. 4. The client is complaining of bleeding gums.

1 A 5-pound weight loss in 1 month would not make the nurse suspect the client is experiencing any long-term complications from taking daily aspirin. 2. Elderly clients often have a loss of hear- ing, but it is not a complication of long- term aspirin use. 3. Elderly clients often lose taste buds, which may cause a funny taste in their mouth, but it is not a complication of taking daily aspirin. ✅4.A complication of long-term aspirin use is gastric bleeding, which could also result in bleeding gums; this data would warrant further intervention Comprehensive Examination. Pharmacology Success

An older adult client is being relocated from a home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome? Providing the client with limited decision making to avoid stressful situations Explaining all procedures and routines to the client's family at the time of relocation Keeping the room clear of personal belongings to reduce the risk of falling Reorienting the client frequently to his or her new location

✅Reorienting the client frequently to his or her new location Relocation stress syndrome usually occurs in older adults shortly after moving from a private residence to a nursing home or assisted-living facility. Characteristic symptoms can include anxiety, confusion, hopelessness, and loneliness. Reorienting the client to the new location helps minimize relocation stress syndrome effects. All procedures and routines should be explained to the client as well as to the family just before they occur. Familiar and special personal belongings are helpful to keep at the client's bedside to minimize the effects of relocation stress syndrome. The client needs opportunities to assist in decision making, which helps the client feel more in control. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

A client has been hospitalized with a non-life-threatening C-spine neck injury. The interprofessional rehabilitation team has worked with the client who is quadriplegic for 4 months. Which outcome indicates that the team's efforts are effective? Personal care is performed with help from the family. Mobility requires multiple assistive devices. Constipation now occurs only 3 days a week. Skin is intact, with no evidence of skin impairment.

✅Skin is intact, with no evidence of skin impairment. The outcome that the skin is intact, with no evidence of skin impairment indicates that the team's efforts are effective. Healthy intact skin indicates good care by this client's interdisciplinary rehabilitation team. A decrease in constipation is not one of the goals of the interdisciplinary rehabilitation team. The client with a C-spine neck injury will have no mobility. Personal care activities are not part of the interdisciplinary rehabilitation program. Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

56. The nurse is preparing to administer morning medications on an oncology floor. Which medication should the nurse administer first? 1. An analgesic to a female client with a headache rated a 3 on a pain scale of 1-10. 2. An anxiolytic to a female client who thinks she might become anxious. 3. A mucosal barrier agent to a male client who has peptic ulcer disease. 4. A biologic response modifier to a male client with low red blood cell counts.

1. A 3 is considered mild pain and could wait until the client whose needs are more emergent is medicated An antianxiety medication is not priority over a client who must take the medica- tion on an empty stomach. This is a po- tential anxiety attack over a physiological problem. ✅3. The medication must be administered prior to a meal. Administering a mu- cosal barrier agent after a meal places medication in the stomach that will coat the food, not the stomach lining. This medication should be adminis- tered first. This medication stimulates the bone mar- row to produce red blood cells; the full effect of the medication will not be seen for 30-90 days. It could be administered after the antianxiety medication and the analgesic.

80. The HCP in the emergency department has prescribed alteplase (Activase) for a client with complaints of new onset of slurred speech, difficulty swallowing, and paralysis of the left arm. Which situations should the nurse question administering the medication? Select all that apply. 1. The client has the comorbid condition of congestive heart failure. 2. The client had abdominal surgery 6 weeks ago for a bleeding ulcer. 3. The client has not had a computerized axial tomography scan done. 4. The client is taking the anticoagulant, warfarin (Coumadin). 5. The client has a history of deep vein thrombosis with pulmonary embolism.

1. Administration of Activase is not con- traindicated in clients who are diagnosed with congestive heart failure. ✅2. Surgery and bleeding ulcers are both reasons for not administering throm- bolytic therapy to the client. ✅3.A CT scan must be done before ad- ministering Activase to make sure that the cerebrovascular accident (CVA) is not being caused by an intracranial hemorrhage. There are three types of stroke: thrombotic, embolic, and hem- orrhagic. If the client is experiencing a hemorrhagic stroke, then administer- ing a medication that dissolves clots could initiate more bleeding and cause death. ✅4. The client receiving anticoagulants cannot receive thrombolytic therapy due to increased bleeding time second- ary to the anticoagulant therapy. This history would indicate the client has experienced a deep vein thrombosis and may have been on anticoagulants but is not on them at this time; therefore, the client can receive thrombolytic therapy Comprehensive Examination. Pharmacology Success

7. The client with major depressive disorder is prescribed the selective serotonin reup- take inhibitor (SSRI) fluoxetine (Prozac). Which information should the nurse discuss with the client? Select all that apply. 1. Tell the client it will take 2 to 3 weeks for the medication to be effective. 2. Instruct the client not to eat any type of tyramine-containing foods such as wines or cheeses. 3. Notify the health-care provider if the client becomes anxious or has an elevated temperature. 4. Tell the client not to stop taking the Prozac abruptly; the medication should be weaned. 5. Explain that tremors and sweating are initial expected side effects.

1. An antidepressant often takes 2-4 weeks to build up its effect and work fully. 2. This would be appropriate for monoamine oxidase inhibitors (MAOIs). ✅3. Serotonin syndrome (SES) is a serious complication of SSRIs that produces mental changes (confusion, anxiety, and restlessness), hypertension, tremors, sweating, hyperpyrexia (elevated tem- perature), and ataxia. Conservative treat- ment includes stopping the SSRI and using supportive treatment. If untreated, it can lead to death. 4.The medication has to be weaned because the client may develop some withdrawal symptoms. The dose is usually gradually reduced before stopping completely at the end of a course of treatment. 5. These are additional signs of serotonin syndrome and should be reported to the health-care provider. Comprehensive Examination. Pharmacology Success

6. The client is experiencing ventricular tachycardia and has a weak, thready apical pulse. Which medication should the nurse prepare to administer to the client? 1. Epinephrine, an adrenergic agonist, intravenous push. 2. Lidocaine, an antidysrhythmic, intravenous push. 3. Atropine, an antidysrhythmic, intravenous push. 4. Digoxin, a cardiac glycoside, intravenous push.

1. Epinephrine is the first medication adminis- tered in a code because it constricts the periphery and shunts the blood to the trunk of the body. ✅2. Lidocaine, an antidysrhythmic, is a drug of choice for treating ventricular dysrhythmias. 3.Atropine is administered for asystole. 4. Digoxin is administered for cardiac failure Comprehensive Examination. Pharmacology Success

39. The nurse administered 25 units of Humulin N to a client with Type 1 diabetes at 0700. Which interventions should the nurse implement? Select all that apply. 1. Assess the client for hypoglycemia around 1800. 2. Ensure the client eats the night-time snack. 3. Check the client's blood glucose level via glucometer. 4. Determine how much food the client ate at lunch. 5. Monitor the client for low blood glucose around 1500.

1. Humulin N is an intermediate-acting insulin that will peak 6-8 hours after ad- ministration; therefore, the client would experience signs of hypoglycemia around 1300-1500 2. The nurse needs to ensure the client eats the night-time (HS) snack to help prevent night-time hypoglycemia if the Humulin N is administered at 1600. This insulin has been administered at 0700, so the nurse should ensure that the client eats lunch and/or a mid-afternoon snack for this administration time. ✅3. The client should have the blood glu- cose checked; it should be done with a glucometer at the bedside. ✅4. Eating the food from the lunch tray will help prevent a hypoglycemic reac- tion because the Humulin N is an in- termediate-acting insulin that peaks in 6-8 hours. ✅5. The Humulin N peaks in 6-8 hours; therefore, the nurse should assess the client for hypoglycaemia around 1500 Comprehensive Examination. Pharmacology Success

75. The nurse is administering therapeutic heparin, an anticoagulant, for a client diagnosed with deep vein thrombosis. Which laboratory value should the nurse monitor? 1. International Normalized Ratio (INR). 2. Prothrombin time (PT). 3. Partial thromboplastin time (PTT). 4. Platelet count.

1. INR is monitored for oral anticoagulant therapy, warfarin (Coumadin). 2. PT is not directly monitored for oral anti- coagulant therapy but will be elevated in clients receiving oral anticoagulants. ✅3. The PTT should be 1.5 to 2.0 times the normal PTT or a control to determine if intravenous heparin is therapeutic. 4. The platelet count is not monitored dur- ing heparin therapy Comprehensive Examination. Pharmacology Success

69. The client diagnosed with anemia is taking an iron tablet, a mineral, daily. Which statement indicates the client needs more medication teaching? 1. "I will not call my HCP if my stools become black or dark green." 2. "I must take my iron tablet with meals and one glass of milk." 3. "I will sit upright for 30 minutes after taking my iron tablet." 4. "I will have to take an iron tablet for about 6 months."

1. Iron turns the stool a harmless black or dark green. This statement indicates the client does understand the medication teaching. ✅2. The iron tablet should be taken be- tween meals and with 8 ounces of water to promote absorption. The iron tablet should not be taken within 1 hour of ingesting antacid, milk, ice cream, or other milk products such as pudding. This statement indicates the client does not understand the medica- tion teaching. Sitting upright will prevent esophageal corrosion from reflux. This statement in- dicates the client understands the medica- tion teaching. The drug treatment for anemia generally lasts less than 6 months. This statement indicates the client understands the med- ication teaching Comprehensive Examination. Pharmacology Success

4. The obstetric clinic nurse is discussing folic acid, a vitamin, with a client who is trying to conceive. Which information should the nurse discuss with the client when taking this medication? 1. Do not use any laxatives containing mineral oil when taking folic acid. 2. Drink one glass of red wine daily to potentiate the medication. 3. This medication will help prevent spina bifida in the unborn child. 4. Notify the health-care provider if the client's vision becomes blurry.

1. Mineral oil will not affect folic acid, but it will inhibit the absorption of vitamin A. 2. The client should avoid drinking alcohol products because they increase folic acid requirements. ✅3.Research has proved that decreased stores of folic acid in the maternal body directly affect the development of spina bifida in the fetus. 4. This would be significant if a client is at risk for developing pregnancy-induced hypertension but not when taking folic acid Comprehensive Examination. Pharmacology Success

66. Which statement best describes the scientific rationale for administering acetylcys- teine (Mucomyst), an antidote, to a child who was brought to the emergency room? 1. Mucomyst neutralizes toxic substances by changing the pH of the poison. 2. Mucomyst binds with bleach, and it is excreted through the bowel. 3. Mucomyst is the antidote for acute acetaminophen (Tylenol) poisoning. 4. Mucomyst induces vomiting, and the client eliminates much of the narcotics.

1. Mucomyst does not neutralize substances by changing their pH. 2. Mucomyst is not used to treat bleach poisonings. Charcoal binds with poisons to form an inert substance that can be eliminated through the bowel because the body is incapable of absorbing char- coal molecules. ✅3. This is the scientific rationale for administering Mucomyst. 4. Mucomyst does not cause emesis. An emetic such as ipecac would induce vomiting.

20. The nurse is administering medications to clients on an orthopedic unit. Which medication should the nurse question? 1. Ibuprofen (Motrin), an NSAID, to a client diagnosed with back pain. 2. Morphine, an opioid analgesic, to a client with back pain rated a 2 on a pain scale of 1-10. 3. Methocarbamol (Robaxin), a muscle relaxant, to a client with chronic back pain. 4. Propoxyphene (Darvon N), a narcotic, to a client with mild back pain.

1. NSAIDs are appropriate interventions for clients diagnosed with back pain. They decrease pain and inflammation. ✅2. Opioid analgesics are administered for pain. The client is in the mild pain range. The nurse would question administering this medication because of its addictive properties. A less potent analgesic should be administered. 3. Muscle relaxant medications are adminis- tered to clients with back pain to relax the muscles and decrease the pain. The nurse would administer this medication. 4. Darvon N is a pain medication. The nurse would administer this medication. Comprehensive Examination. Pharmacology Success

55. The client with rheumatoid arthritis is prescribed hydroxychloroquine sulfate (Plaquenil), a disease-modifying antirheumatic drug (DMARD). Which statement indicates the client understands the medication teaching? 1. "I will get my eyes checked yearly." 2. "I can only have two beers a week." 3. "It is important to take this medication with milk." 4. "I will call my HCP if the pain is not relieved in 2 weeks."

1. Plaquenil can cause pigmentary retinitis and vision loss, so the client should have a thorough vision examination every 6 months; therefore, the client does not understand the medication teaching. 2. Plaquenil may increase the risk of liver toxicity when administered with hepato- toxic drugs, so alcohol use should be eliminated during therapy; therefore, the client does not understand the medication teaching. ✅3. The medication should be taken with milk to decrease gastrointestinal upset. This statement indicates the client un- derstands the medication teaching. 4. The medication takes 3-6 months to achieve the desired response; therefore, the client needs more medication teaching.

16. The nurse is reviewing the laboratory data of a male client receiving chemotherapy. Which intervention should the nurse implement? ⏺Laboratory Data. Client Value. Normal Values WBC 7.4 4.5-11.0 (103) RBC 2.0 M: 4.7-6.1F: 4.2-5.4 Hemoglobin 6.6. M: 13.5-17.5 F: 11.5- 15.5 Hematocrit 19.2 MCV 83 MCHC 31 RDW 12 Reticulocyte 1.4 Platelets 110 150-400 (103) ⏺DIFFERENTIAL Neutrophils. 40 40%-75% (2500-7500/mm3) Lymphocytes 50 20%-50% (1500-5500/mm3) Monocytes 2. 1%-10% (100-800/mm3) Eosinophils 6 0%-6% (0-440/mm3) Basophils 2 0%-2% (0-200/mm3) 1. Assess for an infection. 2. Assess for petechiae. 3. Assess for shortness of breath. 4. Assess for rubor.

1. The WBC count is within normal range; therefore, the nurse would not need to assess for infection. 2. The client's platelet count is less than the normal of 150,000 but still greater than 100,000. Less than 100,000 is thrombocy- topenia. Critical values begin at 50,000, which would cause the client to have petechiae. ✅3. The client's hemoglobin is critically low; therefore, the client might fatigue easily because of oxygen demands on the body and have shortness of breath. 4. The client would not have rubor (redness); the client would be pale. Comprehensive Examination. Pharmacology Success

10. The nurse is administering 0800 medications. Which medication should the nurse question? 1. Misoprostol (Cytotec), a prostaglandin analog, to a 29-year-old male with an NSAID-produced ulcer. 2. Omeprazole (Prilosec), a proton-pump inhibitor, to a 68-year-old male with a duodenal ulcer. 3. Furosemide (Lasix), a loop diuretic, to a 56-year-old male with a potassium level of 3.0 mEq/L. 4. Acetaminophen (Tylenol), a nonnarcotic analgesic, to an 84-year-old with a frontal headache.

1. The client with an ulcer would be pre- scribed a medication that decreases gastric acid secretion; therefore, the nurse would not question administering this medication. Females of childbearing age should not receive this medication because it can cause an abortion. 2. Prilosec is prescribed to treat duodenal and gastric ulcers; the nurse would not question this medication. ✅3. The potassium level is low (3.5- 5.5 mEq/L); therefore, the nurse should question this medication and request a potassium supplement or possibly telemetry. 4. Tylenol is frequently administered for headaches; the nurse would not question this medication.

22. The nurse is caring for clients on the telemetry unit. Which medication should the nurse administer first? 1. The cardiotonic digoxin to the client diagnosed with CHF whose digoxin level is 1.9 mg/dL. 2. The narcotic morphine IVP to the client who has pleuritic chest pain that is rated a 7 on a pain scale of 1-10. 3. The sodium channel blocker lidocaine to the client exhibiting two unifocal PVCs per minute. 4. The ACE inhibitor lisinopril (Vasotec) to the client diagnosed with HTN who has a B/P of 130/68.

1. The digoxin level is within therapeutic range; therefore, the nurse could administer this medication, but it is a routine medica- tion and can be administered at any time. ✅2. Pleuritic pain is pain involving the tho- racic pleura, and pain rated a 7 should be addressed before routine medica- tions are dispensed. A client with two unifocal PVCs in a minute would be considered normal, and no inter- vention would be needed at this time. This blood pressure is within normal lim- its, and this medication could be given within the 30-minute time frame. Comprehensive Examination. Pharmacology Success

9. The client admitted for an acute exacerbation of reactive airway disease is receiving intravenous aminophylline. The client's serum theophylline level is 18 μg/mL. Which intervention should the nurse implement first? 1. Continue to monitor the aminophylline drip. 2. Assess the client for nausea and restlessness. 3. Discontinue the aminophylline drip. 4. Notify the health-care provider immediately.

1. The therapeutic level for theophylline is 10-20 μg/mL; therefore, the nurse should continue to monitor the med- ication because this is within therapeu- tic range. ✅2. If the serum theophylline level rises above 20 μg/mL, the client will experience nau- sea, vomiting, diarrhea, insomnia, and restlessness. This theophylline level may result in serious effects such as convulsion and ventricular fibrillation; therefore, the client should not be assessed first. 3. The nurse should not discontinue the medication because the client's blood level is within therapeutic range. 4. There is no reason to notify the HCP because the theophylline level is within the therapeutic range. Comprehensive Examination. Pharmacology Success

67. The mother of a 2-year-old child calls the emergency department and reports that the child drank some dishwashing detergent. Which question is most important for the nurse to ask the mother? 1. "How much does your child weigh?" 2. "Is your child complaining of a stomach ache?" 3. "Have you called the Poison Control Center?" 4. "Where did you keep the dishwashing soap?"

1. The weight of the child is pertinent infor- mation, but it is not the most important question. ✅2. Most dishwashing liquids are veg- etable-based products and will produce osmotic diarrhea when ingested; there- fore, the nurse should ask about ab- dominal cramping. The soap is not poisonous, but the child may become dehydrated and be uncomfortable. 3. Because the mother has called the emer- gency department it is not priority to know if she called the Poison Control Center. 4. Determining where the soap was is not going to help the child.

54. Which statement is the scientific rationale for prescribing the regimen known as highly active antiretroviral therapy (HAART) to clients diagnosed with HIV infection? 1. HAART will cure clients diagnosed with HIV infection. 2. HAART poses less risk of toxicity than other regimens. 3. HAART can decrease HIV to undetectable levels. 4. HAART is less costly than other medication regimens.

1. There is not a cure for the HIV infection; HIV is a retrovirus that never dies as long as the host is alive. 2. HAART is complex and expensive and poses a risk of toxicity and serious drug interactions. ✅3. Because of HAART plasma levels of HIV can be reduced to undetectable levels with current technology. 4. HAART medications are very expensive Comprehensive Examination. Pharmacology Success

13. The nurse is caring for clients diagnosed with acquired immunodeficiency syndrome (AIDS). Which action by the unlicensed assistive personnel (UAP) warrants immedi- ate action by the nurse? 1. The UAP uses nonsterile gloves to empty a client's urinal. 2. The UAP is helping a client take OTC herbs brought from home. 3. The UAP provides a tube of moisture barrier cream to a client. 4. The UAP fills a client's water pitcher with ice and water.

1. This is standard precaution and does not require intervention by the nurse. ✅2. Herbs are considered medications, and the UAP cannot administer medications to the client even if they are from home. Many herbs will interact with prescribed medications, and the nurse must be aware of what the client is taking. 3. The client can apply his or her own mois- ture barrier protection cream. This does not warrant immediate intervention by the nurse. 4. This is a comfort measure and does not warrant intervention by the nurse. Comprehensive Examination. Pharmacology Success

60. The nurse is preparing to administer lithium (Eskalith), an antimania medication, to a client diagnosed with bipolar disorder. The lithium level is 3.5 mEq/L. Which intervention should the nurse implement first? 1. Administer the medication. 2. Hold the medication. 3. Notify the health-care provider. 4. Verify the lithium level.

1. This level is above therapeutic range; therefore, the nurse should not administer the medication. ✅2. The therapeutic serum level is 0.6 to 1.5 mEq/L; therefore, the first inter- vention is to hold the medication. 3. After holding the medication, the nurse should notify the health-care provider. 4. The nurse should first hold the medica- tion and then verify the level at a later time. Comprehensive Examination. Pharmacology Success

17. The client experienced a full-thickness burn to 45% of the body including the chest area. The HCP ordered fluid resuscitation. Which data indicates the fluid resuscitation has been effective? 1. The client's urine output is less than 30 mL/hour. 2. The client has a productive cough and clear lungs. 3. The client's blood pressure is 110/70. 4. The client's urine contains sediment.

1. This would not indicate the fluid resusci- tation is effective. 2. This would indicate the respiratory system is functioning but does not indicate fluid resuscitation is effective. ✅3.The client's blood pressure indicates that the fluid resuscitation is effective and able to maintain an adequate blood pressure to perfuse the vital organs. 4. This would indicate that the fluid resusci- tation is not effective because this is a sign of decreased urine output.

41. The client diagnosed with hypothyroidism is prescribed levothyroxine (Synthroid). Which assessment data supports the client is taking too much medication? Select all that apply. 1. The client has a 2-kg weight gain. 2. The client complains of being too hot. 3. The client's radial pulse rate is 110 bpm. 4. The client complains of having diarrhea. 5. The client has fine tremors of the hands.

1. Weight gain indicates the client is not tak- ing enough medication. ✅2. Intolerance to hot indicates the client is not taking too much medication. ✅3. Tachycardia, a heart rate greater than 100, is a sign of hyperthyroidism and indicates the client is taking too much medication. ✅4. Increased metabolism, diarrhea, indi- cates the client is taking too much thyroid hormone. ✅5. Fine hand tremors indicate the client is taking too much medication; this is a sign of hyperthyroidism. Comprehensive Examination. Pharmacology Success

1 A student nurse asks an experienced nurse why it is necessary to change the patient's bed every day. The nurse answers: "I guess we have just always done it that way." This answer is an example of what type of knowledge? A. Instinctive knowledge B. Scientific knowledge C. Authoritative knowledge D. Traditional knowledge

1. d. Traditional knowledge is the part of nursing practice passed down from generation to generation, often without research data to support it. Scientific knowledge is that knowledge obtained through the scientific method (implying thorough research). Authoritative knowledge comes from an expert and is accepted as truth based on the person's perceived expertise. Instinct is not a source of knowledge CHAPTER 2 Theory, Research, and Evidence-Based Practice

Am 84-year old female client with advanced dementia is brought to the Emergency Department after an unwitnessed fall at a long-term care facility. The paramedic reports that the nurse at the facility stated that the client was found lying in the hallway approximately one hour earlier. She has unable to ambulate since then, and one leg is noted to be shorter than the other. The client is crying, yet cannot give any history. The Emergency Department nurse assess the client's vitals: T 98.8°F, 160/98 BP, 90 P, 22 R. 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to help you determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What interventions would most likely achieve the desired outcomes for this client? Which interventions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to help you decide which interventions are appropriate and those that should be avoided.) 5. Which interventions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. What client assessment would indicate that your interventions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

1.The fact that the client cannot give a history is relevant, so the nurse will need to collect information from the nurse at the long-term care facility, as well as from any possible other relatives that are engaged with the client. It is important to note that the client is crying and that her vital signs are consistent with the presentation of pain, and that one leg is shorter than the other. 2. A hip fracture is a client condition that is consistent with the most relevant information provided. 3. It is very likely that the client was walking and fell, possibly injuring a hip due to the assessment data of one leg being shorter than another. The pain the client appears to be experiencing is most likely due to this injury. She may also be anxious in an unfamiliar environment. 4. In the emergency department setting, the intervention that would be most helpful to achieve the desired immediate outcome for the client would be arranging for pain control in collaboration with the provider. It is also very important to identify this client as a fall risk and institute fall precautions to meet the desired outcome of keeping the client safe while in the ED. Moving the client's leg and hip should be avoided to decrease the risk for further damage and infliction of pain. 5. Appropriate interventions include communication of the assessment data to the emergency care provider, particularly because the client cannot provide her own history, managing the client's pain, and identifying the client as a fall risk. Because the nurse usually sees the patient before the emergency department provider of care, the priority order would be identifying the client as a fall risk and instituting fall precautions, followed by communicating information to the provider, followed by managing the client's pain. Because the client cannot give a history, the Pain Assessment in Advanced Dementia (PAINAD) scale is a reasonable tool to use (see Chapter 5). 6. In the emergency department setting, the best assessment to demonstrate effectiveness of interventions is that the client's pain is controlled. This could be visualized by watching the client's facial expressions and monitoring for a decrease in vital signs (e.g, a reduction in elevated pulse, blood pressure, and/or respirations) to normal parameters. Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

46. The client who is 38 weeks pregnant and diagnosed with preeclampsia is admitted to the labor and delivery area. The HCP has prescribed intravenous magnesium sulfate, an anticonvulsant. Which data indicates the medication is not effective? 1. The client's deep tendon reflexes are 4+. 2. The client's blood pressure is 148/90. 3. The client's deep tendon reflexes are 2 to 3+. 4. The client's deep tendon reflexes are

1✅ If the client's deep tendon reflexes are 4+, indicating the client may have a seizure at any time, which indicates the medication is not effective. Magnesium sulfate is not administered to treat the client's blood pressure; therefore, this data cannot be used to evaluate the effectiveness of the medication. Magnesium sulfate is administered to pre- vent seizure activity and is determined to be effective and in the therapeutic range when the client's deep tendon reflexes are normal, which is 2+ to 3+ on a 0-4+ scale. A 0 deep tendon reflex indicates the client has received too much magnesium sulfate but the client would not have seizure ac- tivity; therefore, it is effective. The client is at risk for respiratory depression. Comprehensive Examination. Pharmacology Success

A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority? Hematocrit 32% WBC 16/mm3 Slurred speech Yellowed sclerae

✅Slurred speech To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. Sickle cell anemia is characterized by the partial or complete replacement of mature hemoglobin with sickled hemoglobin. The sickled shape of cells can block or reduce the flow of blood through blood vessels, resulting in complications. Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral infarction, which leads to neurological impairment. Because a CVA threatens the life of the client, this is highest priority finding. Hematocrit 32% To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. A hematocrit of 32% is not the priority finding. The hematocrit level of clients who have sickle cell anemia is often below the expected reference range because of the destruction and shortened life span of RBCs. WBC 16/mm3 To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. A WBC count of 16/mm3 is not the priority finding. The WBC level of clients who have sickle cell anemia is often above the expected reference range because of chronic inflammation caused by tissue hypoxia and ischemia. Yellowed sclerae To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. Yellowed sclerae is not the priority finding. Children who have sickle cell anemia often have yellowed sclerae as a result of RBC destruction caused by the sickling; therefore, this finding is not the highest priority. NurseLogic Knowledge and Clinical Judgment Advanced

Question 7 of 13 The nurse is teaching a health and wellness class. What would the nurse include in the discussion of common risk factor for impaired cellular regulation? (Select all that apply.) Select all that apply. Drinking alcohol Smoking Over the age of 70 Poor nutrition Physical inactivity

✅Smoking ✅Over the age of 70 ✅Poor nutrition ✅CORRECT Physical inactivity Risk factors that increase the probability of impaired cellular regulation include smoking, poor nutrition, lack of physical activity, and an age greater than 50. Also, those clients greater than 70 years of age have a significant potential for abnormal cell development. Alcohol intake is not associated with impaired cellular regulation. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further nursing assessment? Pain at the surgical site Verbal stimuli needed to awaken Sore throat upon swallowing Snoring sounds when inhaling

✅Snoring sounds when inhaling Snoring sounds when inhaling may indicate respiratory depression. Postsurgical pain at the surgical site is normal. Requiring verbal stimuli to awaken and a sore throat on swallowing are normal postsedation assessment findings. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops? Place the child on the affected side for several minutes upon completion of instillation. Warm refrigerated drops to room temperature prior to instillation. Pull the pinna of the ear upward and back during instillation. Massage the area posterior to the ear after instillation

✅Warm refrigerated drops to room temperature prior to instillation. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is an appropriate action by the nurse when administering ear drops. Ear drops are topically administered medications, which are slowly absorbed through the skin and primarily provide local results. Because of the anatomy of internal ear structures, it is important to remember that the ear is sensitive to extremes in temperature. Ear drops should be warmed to room temperature prior to instillation to reduce the risk of painful stimuli. Place the child on the affected side for several minutes upon completion of instillation. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is not an appropriate action by the nurse when administering ear drops. The toddler should be positioned on the unaffected side, instead of the affected side, for several minutes after instilling the ear drops to prevent the drops from flowing out of the canal. Pull the pinna of the ear upward and back during instillation. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is not an appropriate action by the nurse when administering ear drops for a toddler. To straighten the auditory canal, the pinna of a client under the age of 3 years should be pulled downward and back, instead of upward and back. Massage the area posterior to the ear after instillation. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is not an appropriate action by the nurse when administering ear drops. The area anterior to the ear, instead of posterior, should be massaged after instillation of the ear drops to facilitate entry of the drops into the ear canal. NurseLogic Knowledge and Clinical Judgment Advanced

The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of The Joint Commission National Patient Safety Goals (NPSG), what will the nurse do as the priority? Ensure that the correct procedure is noted in the client's health record. Witness marking of the left knee site with the client awake and the surgeon present. Communicate with the surgeon confirming the client will have a left knee arthroscopy. Verify with the client that a left knee arthroscopy will be performed

✅Witness marking of the left knee site with the client awake and the surgeon present. The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present. The nurse will also ensure that the correct procedure is in the clients health record; verify with the client that the left knee arthroscopy will be performed, and communicate with the surgeon that the client is having a left knee arthroscopy. However, these are all done after the priority of witnessing the client awake and surgeon present to mark the left knee site. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Which client does the RN in the rehabilitation unit plan to assess first? A 63 year old who had a myocardial infarction (MI) and expresses anxiety about walking A 56 year old with a spinal cord injury and new-onset redness over the sacral area A 70 year old with a joint replacement who needs medication before exercising A 45 year old with multiple sclerosis (MS) reporting constipation

A 56 year old with a spinal cord injury and new-onset redness over the sacral area The RN will first assess the 56 year old with a spinal cord injury and new-onset redness over the sacral area. Because new redness over a bony area may indicate the presence of a stage I pressure injury, the nurse should assess this client's skin as soon as possible and implement interventions to improve skin integrity. The client with constipation, the client with anxiety about walking and the client that needs medication to exercise all need assessment and intervention but are not at as high a risk for acute physiologic complications. Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

26. The client is discussing wanting to quit smoking cigarettes with the clinic nurse. Which intervention is most successful in helping the client to quit smoking cigarettes? 1. Encourage the client to attend a smoking cessation support group. 2. Discuss tapering the number of cigarettes smoked daily. 3. Instruct the client to use varenicline (Chantix), a smoking cessation medication. 4. Explain that clonidine can be taken daily to help decrease withdrawal symptoms.

A smoking cessation support group may be helpful, but nicotine involves a physical withdrawal and medication should be used to help with the withdrawal symptoms. Tapering the number of cigarettes daily is not the most successful method to quit smoking cigarettes. ✅3. Research has shown that 44% of smok- ers were able to quit smoking at the end of 12 weeks with Chantix as com- pared to other smoking cessation med- ications, which have a 30% chance of success. It reduces the urge to smoke. Clonidine is used to help prevent delir- ium tremens in clients with an alcohol dependence Comprehensive Examination. Pharmacology Success

71. The nurse is presenting a lecture on herbs to a group in the community. Which guideline should the nurse discuss with the group? 1. Administer smaller amounts of herbs to babies and young children. 2. Store the herbal remedy in a sunny, warm, moist area. 3. Encourage clients to use herbs as an alternative to other medications. 4. Consumers should think of herbs as medicines; more is not necessarily better.

According to guidelines for prudent use of herbs, babies and young children should not be given any types of herbs. Herbs exposed to sunlight and heat may lose their potency. When presenting information as a nurse, the nurse must encourage a discussion with a health-care provider when substi- tuting herbs for prescribed medications. ✅4. This is a guideline that both con- sumers and health-care providers must be aware of when using herbal therapy Comprehensive Examination. Pharmacology Success

97. The nurse is administering medications to a client diagnosed with Type 1 diabetes. The client's 1100 glucometer reading is 299. Which intervention should the nurse implement? PT—> Height: 69 inches. Weight: 165 pounds Medication ⏺Regular insulin by bedside glucose subcu ac & hs <60 notify HCP <150 0 units 151-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units 351-400 10 units >400 notify HCP 1. Have the laboratory verify the glucose results. 2. Notify the health-care provider of the results. 3. Administer six units of regular insulin subcutaneously. 4. Recheck the client's glucometer reading at 1130.

According to the sliding scale, blood glu- cose results should be verified when less than 60 or greater than 400. The HCP does not need to be notified unless the blood glucose is greater than 400. ✅3. The client's reading is 299; therefore, the nurse should administer six units of regular insulin as per the HCP's order. There is no reason for the nurse to recheck the results. Comprehensive Examination. Pharmacology Success

82. The nurse is preparing to administer a nitroglycerin patch to a client diagnosed with coronary artery disease. Which interventions should the nurse implement first? 1. Date and time the nitroglycerin patch. 2. Remove the old patch. 3. Apply the nitroglycerin patch. 4. Check the patch against the MAR.

After opening the medication the nurse should date and time the patch prior to putting it on the client so that the nurse is not pressing on the client when writing on the patch. The old patch should be removed but not before checking the MAR. The nurse should administer the patch in a clean, dry, nonhairy place while wearing gloves. ✅4. The nurse should implement the five Rights of Medication Administration, and the first ones are to make sure it is the right medication and the right client. Comprehensive Examination. Pharmacology Success

A client has a one-time prescription for morphine 2 mg IV push for breakthrough pain. The drug is available as 5 mg/mL. The nurse administers _____ mL of morphine for one dose.

Answer: 0.4 mL The nurse administers 0.4mL of morphine for one dose. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

Physiological Integrity The family of a client who is near death is concerned about a loud rattling that occurs with the client's breathing. What nursing intervention is appropriate? Select all that apply. 1) Administer hyoscyamine as prescribed to dry up secretions. 2)Turn the client onto one side to help decrease the gurgling with respirations. 3)Suction the client regularly to remove secretions in the bronchi and oropharynx. 4)Assess the client for signs of dyspnea or respiratory distress. 5)Administer diuretics as prescribed to help decrease the wet respirations. 6)Teach the family about the buildup of secretions that occur when a client is near death.

Answer: 1, 2, 4, 6 Rationale: The client is experiencing loud or wet respirations, commonly referred to as a death rattle, as it happens in the end of life. Appropriate nursing interventions include administering hyoscyamine as prescribed to dry up oral secretions, turning the client to one side to help the secretions drain from the bronchi and oropharynx, assessing for signs of dyspnea, and teaching the family about the buildup of secretions that occur when a client is near death. It is not appropriate to suction the client as this is generally ineffective and can be uncomfortable for the dying patient. Administering diuretics is also not appropriate as the secretion are in the respiratory tract and oropharynx and diuretics will not affect these secretions. Cognitive Level: Analyzing Integrated Process: Nursing Process

Physiological Integrity The nurse is teaching a class on pain management strategies. Which client statement requires additional teaching? A. "Persistent pain is a warning in my body that alerts the sympathetic nervous system." B. "Acute pain has a quick onset and is usually isolated to one area of my body." C. "My frozen-shoulder causes musculoskeletal or somatic pain." D. "Nociceptive pain follows a normal and predictable pattern."

Answer: A Rationale: Acute pain, not persistent (chronic) pain serves as a warning signal to alert the sympathetic nervous system. Persistent or chronic pain serves no biologic purpose. The other answer options are all correct and do not require additional teaching. Cognitive Level: Application Integrative Process: Teaching/Learning Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

Physiological Integrity Which documentation will the nurse record for a client who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? A. Reports acute pain at the surgical site. B. Persistent pain reported around the surgical site. C. Experiences neuropathic pain near the surgical site. D. Discomfort has progressed to chronification of pain.

Answer: A Rationale: The nurse will document that the client reports acute pain at the surgical site. Acute pain is commonly associated with surgical procedures and lasts for a short duration. The client does not demonstrate persistent or chronic pain, nor is the pain neuropathic in nature. Acute pain that is poorly controlled and lasts longer than it should can lead to chronification of pain. Cognitive Level: Apply Integrative Process: Nursing Process Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

Safe and Effective Care Environment After assessing four clients, which will the triage nurse identify to be seen first in the ED? A. Client with fever of 101.2°F B. Client who reports slurred speech C. Client who reports bilateral ear pain D. Client with urinary burning and frequency

Answer: A Rationale: According to the three-tiered triage system, clients who present to the ED with the highest acuity needs receive the quickest evaluation; treatment; and prioritized resource utilization. The client who reports slurred speech is at the greatest risk for an adverse outcome if he or she is not seen quickly; therefore, this client would be seen first, followed by the client with fever, and then the clients with ear pain, and urinary burning and frequency. Cognitive Level: Analysis Client Needs Category: Safe, Effective Care Environment: Safety and Infection Control Nursing Process Step: Assessment/Evaluation Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

Health Promotion and Maintenance While a nurse constructs a pedigree during the assessment, the client asks why this is being performed. Which explanation does the nurse provide to the client for this action? A. "This information will help identify your blood relatives' places within your family and describe their health histories." B. "I will use this document to find which person in your family is responsible for introducing a possible genetic mutation into the family." C. "This information will help your primry health care provider to decide whether to prescribe genetic/genomic testing for you." D. "This is a normal way we take information on new clients and is nothing you need to worry about."

Answer: A Rationale: A pedigree is a graphic illustration of family members' places within a family and their medical history. It can be used as one tool to begin to identify health issues that may have a genetic component but is not used to determine "blame" for a genetic mutation. Much more information is needed, as well as consultation with the client before a primary health care provider considers offering genetic/genomic testing. Most desirable is the input of a genetic counselor before such consideration is made because the primary health care provider is not a genetics professional. Although it may be a standard way to document family history information, the client deserves a better explanation of pedigree construction than the one listed in option D. Cognitive Level: Applying or higher Client needs category: Health Promotion and Maintenance Nursing Process Step: Assessing Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

Health Promotion and Maintenance The nurse is conducting assessments for clients at potential risk for Infection. Which population is most at risk for acquiring an Infection? A.A client who had an open incision for abdominal surgery B.A client who has not been immunized for pneumonia or influenza C.A client who works in a high-stress job for an accounting practice D.A client who is 85 years old and in good health

Answer: A Rationale: All four clients are at risk for possible infection but the client who had surgery (A) has an interruption in the skin which usually serves as a barrier or defense against invasion of pathogens into the body.

2. Which of the following factors does the nurse recognize as being a risk for altered sensory perception in the older adult client? A. Diabetes mellitus B. Hypotension C. Osteoarthritis D. Peptic ulcer disease

Answer: A Rationale: Many chronic diseases can affect vision and peripheral sensation. Among the choices, only diabetes mellitus (Choice A) decreases blood flow to the eyes and periphery which causes visual deficit and peripheral neuropathy. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

2.The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? Select all that apply. A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

Answer: A, B, C, D, E Rationale: Anesthesia and analgesics affect the central nervous system and can result in acute confusion and behavioral manifestations such as agitation and combativeness. Overstimulation from pain and an unfamiliar noisy hospital unit can disorient an older adult and this contribute to the onset of delirium. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

Safe and Effective Care Environment The nurse performs an initial health assessment of an older adult. Which assessment findings indicate that the client may be at risk for falls? Select all that apply. A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts F. Has thin papery skin

Answer: A, B, C, D, E Rationale: Choices A and E are normal changes of aging that can prevent the client from seeing where he or she is walking and therefore contribute to falling. Choice B causes lack of feeling in one's legs and feet preventing the older adult from feeling where feet are placed. Using a cane (Choice C) indicates that the client needs assistance with ambulation or balance and is therefore at risk for falling. Choice D is a major risk factor for falls due to adverse drug effects. Choice F does not put the client at risk for falling but is a common physiologic change associated with aging Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

Which observations made by the nurse constructing a client pedigree indicate a probable autosomal recessive (AR) trait transmission of a health problem? Select all that apply. A. Siblings are affected when parents are unaffected. B. The trait appears to "skip" generations. C. Males are affected 8 times more often than females. D. One affected parent does not have affected children. E. The problem is expressed in both siblings in identical (monozygotic) twins F. Males and females are equally affected. G. Over 5 generations, 8 out of 32 family members are affected.

Answer: A, B, C, G Rationale: Finding that both males and females are affected supports that transmission is autosomal but does not indicate whether the pattern is dominant or recessive. When only males are affected, the trait is more likely to be X-linked recessive with some women being carriers and affected women are rare. Recessive traits tend to appear on a pedigree as "skipped generations" because carriers typically do not have the phenotype. Having two or more siblings affected when parents are unaffected suggests an autosomal recessive transmission, where two unaffected carriers have mated. The trait being expressed in about 25% of the total family also is consistent with and AR transmission. Having one affected parent who has only unaffected children can occur with either an AR or an autosomal dominant transmission pattern. Having a genetic disorder expressed in both identical twins can occur with either autosomal recessive or autosomal recessive transmission. Cognitive Level: Applying or higher Client needs category: Physiological Integrity Nursing Process Step: Interpretation Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

1. The nurse is assessing an older adult and notes that the client is at risk for constipation. Which statements will the nurse include in health teaching for this client to promote optimum bowel elimination? Select all that apply. A. "Be sure to include plenty of fresh fruits and vegetables in your diet each day." B. "Eat lots of high fiber foods, including whole grains each day." C. "Be sure to take a laxative every day to clean out your bowels and prevent toxins." D. "Exercise several times a week to keep our bowels working for regular elimination." E. "Drink at least 3 caffeinated beverages every day to keep your bowels stimulated." F. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom."

Answer: A, B, D, F Rationale: To promote bowel elimination and prevent constipation, a common problem among older adults, the nurse teaches the client to include fruits and vegetables, high fiber foods, and fluids (Choices A, B, and F) to soften stool and promote peristalsis. Laxatives are not recommended because they can cause fluid and electrolyte loss and weaken the abdominal wall muscles. Regular exercise also promotes peristalsis (Choice D). Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

The rehabilitation nurse is teaching a client with multiple sclerosis who is wheelchair bound strategies to protect skin integrity. Which teaching will the nurse include? Select all that apply. A. Dry the skin carefully after bathing. B. Do not use pillows to support the body. C. Apply a moisture barrier on the perineum. D. Rub reddened areas of skin to help improve circulation. E. Perform pressure relief strategies at least once an hour. F. Use an air mattress to decrease the need for repositioning.

Answer: A, C, E Rationale: The nurse will teach the client to dry the skin carefully after bathing as this is part of complete skin care and an essential component of prevention of break down. Clients with Multiple Sclerosis may have incontinence and a moisture barrier will help to protect the skin from moisture. Pressure relief strategies are determined based on client ability and should be performed at least once an hour. For example, the client should shift position slightly within the wheelchair, or if arm strength allows, use the arms to raise the buttocks off the wheelchair seat. The nurse would also teach the client to use pillows to support the body. Reddened areas of the skin should not be rubbed as this could damage the already fragile capillary system. While air mattresses can help prevent breakdown that do not replace or reduce the need for repositioning. Cognitive Level: Analysis Integrative Process: Teaching and Learning Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

Physiologic Integrity Which assessment findings indicate to the nurse that a client taking warfarin may have decreased Clotting? Select all that apply. A. Frequent nosebleeds B. Lower leg swelling C. Upper extremity bruising D. Difficulty breathing E. Intermittent chest pain F. Dark stools

Answer: A, C, F Rationale: Decreased Clotting means that the client will likely have signs and symptoms of bleeding. Therefore, A, C, and F indicate that the client is experiencing bleeding. Choices B, D, and E suggest that the client has either a lower extremity clot (increased Clotting) (B)or an embolus (a dislodged clot that traveled to the lungs) (D and E). Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

1. While assessing functional ability, which activities will the nurse document as instrumental activities of daily living (IADLs)? Select all that apply. A. Cooking a meal B. Walking down the hallway C. Getting dressed for the day D. Answering the telephone E. Taking a shower before bed F. Shopping at the local market

Answer: A, D, F Rationale: Cooking a meal, answering the phone, and shopping at the local market are considered instrumental activities of daily living, or activities that are necessary for living in the community. Walking, getting dressed, and bathing are considered activities of daily living (ADL's) and would be documented by the nurse accordingly. Cognitive Level: Analyzing Integrated Process: Communication and Documentation Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

1.A client receiving palliative care for a terminal cancer diagnosis asks the nurse, "Why is this happening to me?" What is the nurse's best response? A. "I don't know. God knows when your time is up on this earth." B. "I'm sorry. I know that this is a very difficult time for you." C. "It's going to be OK; at least you aren't leaving any family behind." D. "We'll make sure that all of your needs are met, so don't worry."

Answer: B Rationale: Acknowledging that a terminal diagnosis is difficult is the most appropriate nursing response. Inferring that God knows when time is up implies a belief in God that may not exist. False reassurance by saying it's okay is not therapeutic and implies that since they are not leaving family there is no reason to be upset. Telling a client not to worry does not allow him or her to express themselves regarding their feelings. Cognitive Level: Application Integrated Process: Nursing Process Chapter 08 - Concepts of Care for Patients at End of

2. The family of a client experiencing terminal dehydration requests that intravenous fluids be started. What is the nurse's best response? A. "We can start fluids to help ease the dehydration." B. "Intravenous fluids can increase discomfort for the client." C. "Intravenous fluids will likely prolong life." D. "Terminal dehydration can be managed better with pain medication."

Answer: B Rationale: With terminal dehydration, administering intravenous fluids can increase discomfort. At this stage, there is multisystem slow down and the body is unable to process the fluids, and this can cause ascites, vomiting, edema, and respiratory distress. Intravenous fluids will not prolong life, but they will make the client less comfortable in this stage. Terminal dehydration does not usually cause discomfort and is managed by keeping the client's oral cavity moist. Cognitive Level: Application Integrated Process: Nursing Process Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

Safe, Effective Care Environment A client reports increasing diffuse pain in the entire right leg. What is the nurse's priority action at this time? A.Elevate the right leg on a pillow. B.Perform a peripheral vascular assessment. C.Check for swelling in the right leg. D.Notify the Rapid Response Team immediately.

Answer: B Rationale: The client may have decreased peripheral Perfusion in the right leg, so the nurse needs to first perform a complete peripheral vascular assessment before making a decision about the next steps. There are no assessment data presented that indicate a need to elevate the affected leg (A) and checking for swelling is only part of a vascular assessment (Choice C). It is too soon to determine if the Rapid Response Team will need to be notified without adequate assessment data (Choice D). Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

Physiological Integrity An older adult's furosemide dosage was increased two days ago to 40 mg daily. This morning the nurse observes that the client has become confused and very weak. What is the nurse's best action? A. Encourage fluid intake. B. Withhold this morning's dose of furosemide. C. Review the most recent serum electrolyte levels. D. Place the patient on strict intake and output.

Answer: B Rationale: Furosemide can cause hyponatremia which causes weakness and acute confusion. Therefore, the nurse would not want to give her more of the drug which might worsen the patient's condition. Therefore, Choice B is the best action at this time. The nurse would also want to check lab data for the sodium and potassium levels, but the best action at this time is to withhold the drug. Choices A and C relate to diuretic therapy but don't address the patient's confusion or weakness. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

2. A client has been receiving the same dose of an intravenous opioid for two days to manage post-surgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? A.There is likely a history of addiction. B.Tolerance to the opioid is developing. C.Physical dependence is developing. D.The client is opioid-naïve.

Answer: B. Rationale: A client who has been receiving the same dose of an opioid for several days and now reports that the drug is not controlling the pain is likely developing tolerance. This is not the same thing as addiction or physical dependence. Physical dependence is manifested when a drug is stopped and the client shows withdrawal symptoms. Tolerance means the body has adapted to the drug and the client may require an increased dose or switching to a different drug for pain control. An opioid-naïve person has not recently taken enough opioid on a regular basis to become tolerant to the effects of an opioid. Tolerance does not indicate addiction or a history of addiction. Cognitive Level: B Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

Psychosocial Integrity The nurse is caring for a 25-year old client with a new spinal cord injury resulting in tetraplegia. The client states, "I won't be able to do any activities that I enjoy now". What is the priority nursing intervention? A. Encourage the client to explore new activities that they can do. B. Teach the client about reasonable goals for activities. C. Allow the client time to discuss feelings of loss related to the injury. D. Consult pastoral care to provide encouragement to the client.

Answer: C Rationale: This client has a new injury with tetraplegia. This means there is partial or total loss of use of all four limbs. The priority nursing intervention is to allow the client time to grieve for the loss related to the injury. This includes discussing the feelings with the client. The next action, with the client's permission would be to consult pastoral care for encouragement and support. Teaching the client about reasonable goals and encouragement to explore new activities are both appropriate interventions. However, the client must have time to grieve the loss in function before teaching and considering new activities. Cognitive Level: Analysis Integrated Process: Caring Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

Physiological Integrity A client receiving palliative care, who has advanced dementia, is non-verbal, restless and moans when the family attempts to touch or comfort the client. Which nursing intervention is appropriate for this client? A.Administer acetaminophen 650 mg by rectally for pain. B. Instruct the family to avoid touching the client to prevent pain. C. Provide passive range of motion to increase mobility once a shift. D. Obtain a prescription for transdermal fentanyl for pain

Answer: D Rationale: The client is likely experiencing severe pain and needs to be treated with a strong analgesic rather than a mild one like acetaminophen. Further, rectal administration is likely to cause unnecessary discomfort. The purpose of palliative care is to promote comfort. Instructing the family to avoid touching the client is not appropriate, as the family and the client can benefit from supportive touch. Cognitive Level: Understanding Integrated Process: Caring Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

Health Promotion and Maintenance A client with a medical problem reports that her brother was diagnosed with schizophrenia last year. She tells the nurse she is considering using a direct-to-consumer genetic/genomic testing service to determine her risk for also developing the disorder. What is the most relevant reason for the nurse to discourage this action? A. Direct-to consumer genetic tests are only performed once the person with diagnosis has first been tested. B. Such tests are expensive and, when not ordered by a health-care provider, they are not covered by insurance. C. These tests are often misused by employers to support the dismissal of employees at increased genetic risk for a disorder. D. People using such tests may not receive adequate professional counseling for interpretation of results and accurate risk assessment.

Answer: D Rationale: Although it is true that the tests can be expensive and not covered by insurance, a major concern is that the direct-to-consumer testing often does not have appropriate genetic professionals to interpret results and assess risk. The outcomes of such testing could have a devastating effect on a person who tested positive but did not have appropriate access to a counselor for interpretation of this result. Thus clients could make life decisions without accurate information. Results of any genetic/genomic testing cannot be used as a reason to dismiss an employee who is found to have an increased genetic risk for development of a disorder. Direct-to-consumer genetic/genomic testing does not require that a relative who actually has the disorder first undergo testing before other family members can be tested. Cognitive Level: Applying or higher Client needs category: Health Promotion and Maintenance Nursing Process Step: Intervention Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

What is the generalist registered nurse's role related to patient care within a system? Select all that apply. A. Caring B. Teaching C. Collaborating D. Advocating E. Researching F. Prescribing

Answers: A, B, C, D, E Rationale: The generalist nurse's roles include caring, teaching, collaborating, advocating, and researching. Prescribing is a role of health care providers such as physicians, physician assistants, and advance practice registered nurses (APRNs). Cognitive Level: Understanding Client Needs Category: Safe and Effective Care Environment: Management of Care Nursing Process Step: Assessment/Evaluation Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

Safe and Effective Care Environment Which environments of care will the nurse recognize as components of the healthcare system? Select all that apply. a) Long term care b) Primary care c) Free standing emergency department d) National League of Nursing e) Patient-centered medical home f) World Health Organization

Answers: A, B, C, E Rationale: Long term care, primary care, free standing emergency department, and the patient-centered medical home are environments of care. The National League for Nursing and the World Health Organization are not environments of care. Cognitive Level: Understanding Client Needs Category: Safe and Effective Care Environment: Management of Care Nursing Process Step: Assessment/Evaluation Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

Physiological Integrity A nurse assures a client experiencing abdominal surgical pain that comfort measures, including drug therapy, will be provided as the client needs them. Which ethical principles apply in the situation? Select all that apply. A.Beneficence B.Social justice C.Autonomy D.Fidelity E.Veracity

Answers: A, D, E Rationale: In this situation, the nurse is planning to provide positive measures ("good") for the client (beneficence) (Choice A) and is obligated to follow-through with this promise (fidelity) (Choice D) and be truthful (veracity) (Choice E). The client is not autonomous because of inability to self-manage care (Choice C). Social justice is about fairness and does not apply in this scenario (Choice B). Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

51. The long-term care nurse is administering botulinum toxin type A (Botox), an anti- spasmodic, to a client diagnosed with a brain attack. Which statement best describes the scientific rationale for administering this medication? 1. This medication is administered for the cosmetic effect to reduce wrinkles. 2. This medication reduces muscle spasticity associated with strokes. 3. This medication will improve the client's residual limb strength. 4. This medication will decrease the pain associated with neuropathy.

Botox will reduce wrinkles, but that is not why it is administered to a client with a cerebrovascular accident, a brain attack. The paralysis of the facial muscles lasts from 3-6 months. ✅2. Botox produces partial chemical dener- vation of the muscle, resulting in local- ized reduction in muscle activity and spasticity. This medication will not improve limb weakness. This medication does not help with pain secondary to neuropathy. Comprehensive Examination. Pharmacology Success

17 of 19 The nurse is assessing an older adult client to identify possible factors that may negatively impact the client's nutritional status. Which risk factors would the nurse include? (Select all that apply.) Select all that apply. Loneliness or depression Inadequate financial resources Constipation Lack of transportation Tooth loss or poorly fitting dentures Decreased mobility

CORRECT Loneliness or depression Inadequate financial resources Constipation Lack of transportation Tooth loss or poorly fitting dentures Decreased mobility All of these factors can prevent clients from eating adequate amounts of or healthy foods. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

18 of 19 The nursing is using the pain assessment in advanced dementia pain scale to assess a client. What categories of pain indicators will the nurse assess? (Select all that apply.) Select all that apply. Body language Facial expression Breathing pattern Ability to calm the client Ability to distract the client Picking at skin or clothing Vocalizations

CORRECT ✅Body language ✅Facial expression ✅Breathing pattern ✅Ability to calm the client ✅Vocalizations Pain Assessment in Advanced Dementia (PAINAD) scale has been tested in patients with severe dementia (Herr et al., 2011). The tool groups behavioral indicators into five categories for scoring using a graduated scale of 0 (least intense behaviors) to 2 (most intense behaviors) per category for a maximum behavioral score of 10: · Breathing (independent of vocalization) · Negative vocalization · Facial expression · Body language · Consolability (ability to calm the patient) Picking at the skin or clothing as well as ability to distract the client are not portions of the PAINAD scale Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

What dose CUS stand for

CUS is another communication tool, recommended for use to assist in effective communication related to patient-safety concerns. ❑CUS, which stands for •I'm Concerned, •I'm Uncomfortable, •This is unSafe (This is a Safety issue), was developed from an airline safety program and provides mutually agreed-upon critical language for communication

4.The client who has been found to have a mutation in gene allele that greatly increases the risk for future development of polycystic kidney disease that may eventually require kidney transplantation as therapy had received counseling by a geneics professional. The client now asks the nurse who was present during the counseling to be present during disclosure of this information to the family. What is/are the nurse's role(s) in this situation? Select all that Apply. A. Interpreter of the findings B. Assurer of the client's correct understanding C. Genetic counselor D. Client Support E. Client advocate F. Family advocate G. Assessor of who might be a kidney donor

Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

9 of 18 The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? "Do you believe in God?" "Where have you been attending church?" "Tell me about religion in your life." "What gives you purpose in life?"

Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

1 of 15 For which client will the nurse choose to perform SBIRT? Client who continues to use alcohol Client with recurrent asthma admissions Client with infection who did not complete antibiotic therapy Client with a sports injury reporting extreme pain

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

10 of 15 The nurse is caring for a client in the ED who reports speaking English as a second language. Which nursing intervention is appropriate? Obtain another nurse to listen to the conversation. Contact an interpreter contracted through the hospital. Request that the health care provider stay present. Ask the client's spouse to assist with communication.

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

11 of 15 The nurse routinely screens all clients in the ED for depression. Which client does the nurse identify at the highest risk for depression? A 59-year-old Caucasian male A 46-year-old Asian-American female A 22-year-old African-American female A 30-year-old Hispanic male

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

13 of 15 Resuscitation for a client who sustained cardiac arrest in the emergency department (ED) was unsuccessful. Which nursing intervention is appropriate when the family members ask to view the body? (Select all that apply.) Select all that apply. Contact the chaplain to accompany the family while viewing the client. Cover the client with a sheet, leaving the face exposed. Brighten the lights in the room so the family can better see the client. Remove lines and indwelling tubes unless a forensic investigation is anticipated. Express sympathy by stating, "the client is in a better place now."

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

14 of 15 The nurse suspects that a client in the ED may be a victim of human trafficking. Which signs and symptoms support this assumption? (Select all that apply.) Select all that apply. Reports having had three abortions in the past 2 years. Missing patches of hair. Allows the accompanying person to answer all nursing questions. Notes various ED visits for sexually transmitted infections (STIs) recorded in the electronic health record. Burns in various places on the body.

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

15 of 15 The nurse in the ED is preparing to discharge a client with a visual defect who needs to take an antibiotic at home. Which method will the nurse use to teach about drug therapy? (Select all that apply.) Select all that apply. Instructions written at an 8th grade reading level Verbal teaching to the client Teaching by an interpreter Educational materials printed in Spanish Distribution of large-print reading material

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

2 of 15 A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to contact to provide care for this client? Forensic nurse examiner Social worker Psychiatric crisis nurse Physician or health care provider

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

4 of 15 A client comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation? Completing documentation Performing assessment Setting priorities Interpret findings

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

5 of 15 There has been an explosion at a local refinery with numerous reported injuries. Which client does the nurse identify as the priority for treatment? Older adult with heavy bleeding Child with an open fracture of the arm Teenager with contusions of the lower extremities Adult with a head injury

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

6 of 15 The nurse is caring for a client who may be the victim of domestic violence. When the health care provider discharges the client to home, what is the appropriate nursing action? Consult with Social Services. Call the police. Instruct the client to go to a neighbor's house. Discharge per the health care provider's orders.

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

7 of 15 An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a Glasgow Coma Scale score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client? Level III Level IV Level II Level I

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

8 of 15 The nurse is caring for a client after a motor vehicle crash whose vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. After assessing the Glasgow Coma Scale score as 15, and noting no apparent injuries other than a seat belt abrasion, what will the nurse do next? Discharge to home. Clean the seat belt abrasion. Perform ongoing monitoring. Obtain blood alcohol level.

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

Question 8 of 15 Into which environment of care would the nurse anticipate sending a client who is experiencing complications from COVID-19? Medical home Community health care Inpatient care Rehabilitation care

Community health care ✅CORRECT Inpatient care Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

What response does the nurse expect for a client who has a normal gene allele and an abnormal gene allele for insulin and the area around the abnormal gene allele is heavily methylated? A.Normal insulin is produced in lower than normal amounts. B.Normal insulin is produced in normal amounts. C.Abnormal insulin is produced in high amounts. D.No insulin is produced.

Correct Answer: A Rationale: Methylation of the abnormal gene allele is likely to suppress its transcription, effectively blocking its production of any abnormal or normal insulin. This would allow the normal insulin allele to be expressed exclusively, which would result in the production of normal insulin. However, with only one allele active, the person would produce lower amounts of insulin. Cognitive Level: Understanding Client needs category: Physiological Integrity Nursing Process Step: N/A Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

Physiological Integrity: Pharmacological and Parenteral Therapies The surgery for a client scheduled for an 8:00 AM procedure is delayed until 11:00 AM. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 AM as originally prescribed. B. Adjust the administration time to be given at 10:00 AM. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

Correct Answer: B Rationale: According to the Surgical Care Improvement Project (SCIP) guidelines, prophylactic antibiotics should be given within one hour before the surgical incision. Cognitive Level: Application Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process Step: Implementation Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Physiological Integrity: Reduction of Risk Potential The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D.If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

Correct Answers: A, C, D, E Rationale: Teaching regarding postoperative leg exercises should include having the client begin practicing the exercises before surgery; repeating the exercises several times daily for each leg; pushing the ball of the foot into the bed until the calf and thigh muscles contract; discontinuing exercises and contacting the surgeon if pain of warmth in the calf is present; and pointing toes of one foot towards the bottom of the bed, then towards the face, and switching. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Implementation Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin? Cyanosis Jaundice Erythema Pallor

Cyanosis In this item, you need nursing knowledge related to oxyhemoglobin and its effect on skin color. Based on an understanding of these two concepts, you can identify indicators of decreased oxyhemoglobin. This item requires critical thinking because you have to analyze the findings in relation to the expected color of the skin when there is a decreased level of oxyhemoglobin in the blood. Oxyhemoglobin is the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it. In clients who have anemia, the RBCs are reduced, by function or in number, to the point that peripheral tissues are not receiving adequate oxygen because of a decreased amount of circulating oxyhemoglobin. The reduced oxygen supply to the tissues causes changes to the client's skin color. Cyanosis is not caused by a reduced amount of oxyhemoglobin. Reduced oxygen levels in the tissues because of an increase in circulating deoxygenated hemoglobin results in cyanosis, which is a bluish color to the skin. Jaundice In this item, you need nursing knowledge related to oxyhemoglobin and its effect on skin color. Based on an understanding of these two concepts, you can identify indicators of decreased oxyhemoglobin. This item requires critical thinking because you have to analyze the findings in relation to the expected color of the skin when there is a decreased level of oxyhemoglobin in the blood. Oxyhemoglobin is the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it. In clients who have anemia, the RBCs are reduced, by function or in number, to the point that peripheral tissues are not receiving adequate oxygen because of a decreased amount of circulating oxyhemoglobin. The reduced oxygen supply to the tissues causes changes to the client's skin color. Jaundice is not caused by a reduced amount of oxyhemoglobin. Jaundice is a yellow-orange color of the skin caused by increased amounts of bilirubin being deposited in the tissues. Erythema In this item, you need nursing knowledge related to oxyhemoglobin and its effect on skin color. Based on an understanding of these two concepts, you can identify indicators of decreased oxyhemoglobin. This item requires critical thinking because you have to analyze the findings in relation to the expected color of the skin when there is a decreased level of oxyhemoglobin in the blood. Oxyhemoglobin is the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it. In clients who have anemia, the RBCs are reduced, by function or in number, to the point that peripheral tissues are not receiving adequate oxygen because of a decreased amount of circulating oxyhemoglobin. The reduced oxygen supply to the tissues causes changes to the client's skin color. Erythema is not caused by a reduced amount of oxyhemoglobin. Erythema is a red color of the skin caused by increased blood flow, which enhances the visibility of oxyhemoglobin. ✅Pallor MY ANSWER In this item, you need nursing knowledge related to oxyhemoglobin and its effect on skin color. Based on an understanding of these two concepts, you can identify indicators of decreased oxyhemoglobin. This item requires critical thinking because you have to analyze the findings in relation to the expected color of the skin when there is a decreased level of oxyhemoglobin in the blood. Oxyhemoglobin is the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it. In clients who have anemia, the RBCs are reduced, by function or in number, to the point that peripheral tissues are not receiving adequate oxygen because of a decreased amount of circulating oxyhemoglobin. The reduced oxygen supply to the tissues causes changes to the client's skin color. Pallor is caused by a reduced amount of oxyhemoglobin. Pallor is a decrease in the coloring of the peripheral tissues that is caused by an overall reduction in the blood flow or by a decrease in the number of RBCs that contain oxyhemoglobin, which reduces the visibility of oxyhemoglobin. NurseLogic Knowledge and Clinical Judgment Beginner

A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? Determining the client's respiratory rate Measuring the client's chest diameter Obtaining the client's level of oxygen saturation Checking the client's depth of respirations

Determining the client's respiratory rate In this item, you need nursing knowledge related to what the term tissue perfusion means. Based on an understanding of this, you can identify which of the following findings is an indicator of adequate tissue perfusion. This item requires foundational thinking because you only need to identify which of the following options describes a technique for measuring tissue perfusion. Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Determining the client's respiratory rate is not an appropriate technique of measuring perfusion. The respiratory rate allows the nurse to determine if breathing is rapid, slow, or within the expected reference range for a client who has COPD. How much oxygen reaches the blood is affected by more variables than just the respiratory rate. Measuring the client's chest diameter In this item, you need nursing knowledge related to what the term tissue perfusion means. Based on an understanding of this, you can identify which of the following findings is an indicator of adequate tissue perfusion. This item requires foundational thinking because you only need to identify which of the following options describes a technique for measuring tissue perfusion. Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Measuring the client's chest diameter is not an appropriate technique of measuring perfusion. Comparison of the anteroposterior chest diameter to the lateral chest diameter can indicate a ratio that is consistent with COPD caused by air trapping, which results in the chest having a rounded, rather than an oval, shape. However, how much oxygen reaches the blood is affected by more variables than just the shape of the chest. ✅Obtaining the client's level of oxygen saturation MY ANSWER In this item, you need nursing knowledge related to what the term tissue perfusion means. Based on an understanding of this, you can identify which of the following findings is an indicator of adequate tissue perfusion. This item requires foundational thinking because you only need to identify which of the following options describes a technique for measuring tissue perfusion. Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Obtaining the client's level of oxygen saturation level is an appropriate technique of measuring perfusion. Oxygen saturation measures the percent of hemoglobin bound with oxygen that is being perfused through the arteries and into the tissues. Checking the client's depth of respirations In this item, you need nursing knowledge related to what the term tissue perfusion means. Based on an understanding of this, you can identify which of the following findings is an indicator of adequate tissue perfusion. This item requires foundational thinking because you only need to identify which of the following options describes a technique for measuring tissue perfusion. Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Checking the client's depth of respirations is not an appropriate technique of measuring perfusion. The depth of respirations allows the nurse to determine if respirations are deep or shallow by determining the degree of lung expansion. However, how much oxygen reaches the blood is affected by more variables than just depth of respirations.

83. The client with congestive heart failure is taking digoxin (Lanoxin), a cardiac glycoside. Which data indicates the medication is ineffective? 1. The client's blood pressure is 110/68. 2. The client's apical pulse rate is 68. 3. The client's potassium level is 4.2 mEq/L. 4. The client's lungs have crackles bilaterally.

Digoxin does not affect the client's blood pressure; therefore, it cannot be used to de- termine the effectiveness of the medication. The client's apical pulse must be assessed prior to administering the medication, but it is not used to determine the effective- ness of the medication. The client's potassium level must be as- sessed prior to administering the medica- tion, but it is not used to determine the effectiveness of the medication. ✅4. Signs or symptoms of CHF are crack- les in the lungs, jugular vein distention, and pitting edema; therefore, the med- ication is not effective Comprehensive Examination. Pharmacology Success

Need to know

Even if a task is delegatable, UAP are not permitted to perform it independently. Your hospital may allow UAP to ambulate patients but only you can decide if your UAP should ambulate a particular patient at a particular time. The domains of learning guide the learning outcomes. It is helpful to remember the following: "cognitive" is "knowledge"; "psychomotor" is "action"; "affective" is "feelings." Nursing deals with the public. Thus, the ultimate goal of all laws and professional regulations involved with nursing practice is public safety. Although, at times, a nurse may be responsible for having a patient sign the consent form, in all instances, the nurse is responsible for answering any questions the patient may have and for making sure that the signed consent form is on the patient's chart. If the nurse determines that the patient is unsure or has questionable understanding, the nurse is responsible for notifying the person who had obtained the consent about the situation so that that person can clarify or reexplain the information.

42. The client diagnosed with chronic pancreatitis is complaining of steatorrhea. Which medication should the nurse prepare to administer? 1. Humalog, a fast-acting insulin, intravenously, then monitor glucose levels. 2. Pancrelipase (Cotazym) sprinkled on the client's food with meals. 3. Humulin R subcutaneously after assessing the blood glucose level. 4. Ranitidine (Zantac), a histamine2 receptor blocker, orally.

Humalog is not administered intravenously, and glucose levels should be monitored prior to insulin administration. ✅2. Steatorrhea is fatty, frothy stools that indicate the pancreatic enzymes are not sufficient for digestive purposes. The nurse should be prepared to ad- minister pancreatic enzymes. Humulin R insulin is administered by slid- ing scale to decrease blood glucose levels. Clients with pancreatitis should be moni- tored for the development of diabetes mellitus. Zantac would not treat the client's symptoms Comprehensive Examination. Pharmacology Success

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? Isopropyl alcohol Chlorhexidine gluconate (Hibiclens) Chlorine (bleach) Iodophor

Isopropyl alcohol This item requires foundational thinking because you have to recall knowledge specific to disinfectants that are effective against bloodborne pathogens. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. Isopropyl alcohol is an antiseptic often found in hand sanitizers and is effective against bacteria, tuberculosis, fungi, and viruses. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Isopropyl alcohol should not be used to clean the spill. Chlorhexidine gluconate (Hibiclens) This item requires foundational thinking because you have to recall knowledge specific to disinfectants that are effective against bloodborne pathogens. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. Chlorhexidine gluconate is an antiseptic skin cleanser with bactericidal properties and is effective against bacteria and viruses. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Chlorhexidine gluconate should not be used to clean the spill. ✅Chlorine (bleach) This item requires foundational thinking because you have to recall knowledge specific to disinfectants that are effective against bloodborne pathogens. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. Chlorine is a disinfectant that is effective against bacteria, tuberculosis, spores, fungi, and viruses, and is specifically recommended for cleaning blood spills. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Chlorine should be used to clean the spill. Iodophor This item requires foundational thinking because you have to recall knowledge specific to disinfectants that are effective against bloodborne pathogens. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. Iodophor is a disinfectant that is effective against bacteria, tuberculosis, spores, fungi and viruses, and is used to cleanse equipment. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. If diluted, iodophor is acceptable for use on skin. This solution should not be used to clean the spill. NurseLogic Knowledge and Clinical Judgment Beginner

58. The nurse administered a narcotic pain medication 30 minutes ago to a client diagnosed with cancer. Which data indicates the medication was effective? 1. The client keeps his or her eyes closed and the drapes drawn. 2. The client uses guided imagery to help with pain control. 3. The client is snoring lightly when the nurse enters the room. 4. The client is lying as still as possible in the bed.

Keeping the eyes closed and drapes drawn would not indicate the pain medication is effective. These actions may be the client's way of dealing with the pain. Using guided imagery is an excellent method to assist with the control of pain, but its use does not indicate effectiveness of the medication. ✅3. Light snoring indicates the client is asleep, which would indicate the med- ication is effective. This action may be the client's way of dealing with the pain, but it does not indi- cate the medication is effective Comprehensive Examination. Pharmacology Success

29. The client receiving telemetry is exhibiting supraventricular tachycardia. Which antidysrhythmic medication should the nurse administer? 1. Lidocaine. 2. Atropine. 3. Adenosine. 4. Epinephrine.

Lidocaine suppresses ventricular ectopy and is a first-line drug for the treatment of ventricular dysrhythmias Atropine decreases vagal stimulation, which increases the heart rate, and is the drug of choice for asystole, complete heart block, and symptomatic bradycardia. ✅3. Adenosine is the drug of choice for ter- minating paroxysmal supraventricular tachycardia by decreasing the auto- maticity of the SA node and slowing conduction through the AV node. Epinephrine constricts the periphery and shunts the blood to the central trunk and is the first medication administered in a client who is coding Comprehensive Examination. Pharmacology Success

84. The client receiving telemetry is showing ventricular fibrillation and has no pulse. Which medication should the nurse administer first? 1. Lidocaine. 2. Atropine. 3. Adenosine. 4. Epinephrine.

Lidocaine suppresses ventricular ectopy and is a first-line drug for the treatment of ventricular dysrhythmias, but it is not the first medication to be administered in a code. Atropine decreases vagal stimulation, which increases the heart rate and is the drug of choice for asystole, complete heart block, and symptomatic bradycardia. Adenosine is the drug of choice for termi- nating paroxysmal supraventricular tachy- cardia by decreasing the automaticity of the SA node and slows conduction through the AV node. ✅4. Epinephrine constricts the periphery, shunts the blood to the central trunk, and is the first medication adminis- tered in a client who is coding. The client does not have a pulse; therefore, the nurse must call a code Comprehensive Examination. Pharmacology Success

A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills? Living wills require a written prescription from the provider to be legal. Living wills allow the client to designate a health care proxy. Living wills ensure hospitals provide emergency care regardless of health coverage. Living wills detail treatment wishes of the client in the event of terminal illness.

Living wills require a written prescription from the provider to be legal. In this item, you need knowledge of advance directives. Based on this information, you can select the option that would be appropriate to include when teaching staff about living wills. This is a foundational item because you have to recall knowledge specific to the content and purpose of a living will. Advance directives include both living wills and durable powers of attorney for health care. Living wills must be signed by the client to be legal, but a prescription from the provider is not necessary. A written prescription from the provider is required for a do-not-resuscitate (DNR) order to take effect. This information is inaccurate and should not be included in the teaching about living wills. Living wills allow the client to designate a health care proxy. In this item, you need knowledge of advance directives. Based on this information, you can select the option that would be appropriate to include when teaching staff about living wills. This is a foundational item because you have to recall knowledge specific to the content and purpose of a living will. Advance directives include both living wills and durable powers of attorney for health care. The durable power of attorney for health care allows the client to designate a health care proxy, not the living will. This information is inaccurate and should not be included in the teaching about living wills. Living wills ensure hospitals provide emergency care regardless of health coverage. In this item, you need knowledge of advance directives. Based on this information, you can select the option that would be appropriate to include when teaching staff about living wills. This is a foundational item because you have to recall knowledge specific to the content and purpose of a living will. Advance directives include both living wills and durable powers of attorney for health care. The Emergency Medical Treatment and Active Labor Act ensures that hospitals provide emergency care regardless of health coverage, not the living will. This information is inaccurate and should not be included in the teaching about living wills. ✅Living wills detail treatment wishes of the client in the event of terminal illness. In this item, you need knowledge of advance directives. Based on this information, you can select the option that would be appropriate to include when teaching staff about living wills. This is a foundational item because you have to recall knowledge specific to the content and purpose of a living will. Advance directives include both living wills and durable powers of attorney for health care. The living will details treatment wishes of the client in the event of terminal illness or persistent vegetative state. This information is accurate and should be included in the teaching about living wills. NurseLogic Knowledge and Clinical Judgment Beginner

27. Each of the following clients has a head injury. Which client would the nurse question administering the osmotic diuretic mannitol (Osmitrol)? 1. The 34-year-old client who is HIV positive. 2. The 84-year-old client who has glaucoma. 3. The 68-year-old client who has congestive heart failure. 4. The 16-year-old client who has cystic fibrosis.

Mannitol would not be contraindicated in a client who is HIV positive. Mannitol, an osmotic diuretic, would not be contraindicated in a client who has glaucoma. The osmotic diuretic medica- tion Diamox is administered to clients with glaucoma. ✅3. Because mannitol will pull fluid off the brain by osmosis into the circulatory system it can lead to a circulatory over- load, which the heart could not handle because the client already has CHF. This client would need an order for a loop diuretic to prevent serious cardiac complications. The client is 16 years old, and even with CF the client's heart should be able to handle the fluid-volume overload Comprehensive Examination. Pharmacology Success

93. The client post-gastrectomy has a patient-controlled analgesia (PCA) pump. Which data indicates the client and family understand the instructions regarding the PCA pump? 1. The family pushes the PCA button whenever the time limit has expired. 2. The client uses the PCA before turning, coughing, and deep breathing. 3. The family discourages the client from using the PCA pump. 4. The client pushes the PCA button when the pain is an 8 or 9 on the pain scale of 1-10.

No one but the client should push the PCA button. If the client has pain, the client should push the button. Family members administering doses "whenever" could overdose the client. This statement indi- cates the client and family do not under- stand the correct use of the PCA ✅2. The client should premedicate himself or herself with the PCA so that effec- tive coughing, deep breathing, and turning can be performed with some degree of comfort. This indicates the client understands the teaching. The family should let the client decide when he or she is in pain and the client should use the PCA at that time. This statement indicates the family does not understand the correct use of the PCA. The client should use the PCA before the pain level reaches this level. This state- ment indicates the client does not under- stand the correct use of the PCA. Comprehensive Examination. Pharmacology Success

Question 3 of 13 A nurse participates as part of a quality improvement (QI) team to develop a plan to "reduce deep vein thrombosis on a surgical unit." What part of the PICO(T) question does this statement represent? P C O I

P O stands for Outcome that is desired as a result of the work of the QI team. C O stands for Outcome that is desired as a result of the work of the QI team. ✅ O O stands for Outcome that is desired as a result of the work of the QI team. I O stands for Outcome that is desired as a result of the work of the QI team. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

48. The client with low back pain syndrome is prescribed chlorzoxazone (Parafon Forte), a skeletal muscle relaxant. Which statement by the client warrants intervention by the nurse? 1. "I have not had the flu since I started the medication." 2. "I am always drowsy after taking this medication." 3. "I find driving my car difficult when I take my back pain medicine." 4. "If I miss a dose I wait until the next dose time to take a pill."

Parafon Forte would not have an effect on whether or not the client has had the flu. This medication can make the client drowsy; this is why the nurse teaches the client not to drive or operate heavy ma- chinery when taking a muscle relaxant. ✅3 The client should not be driving at all when the medication makes them less than alert. The nurse should address this with the client. This would keep the client from overdos- ing on the medication Comprehensive Examination. Pharmacology Success

79. Which statement is the scientific rationale for prescribing dexamethasone (Decadron), a glucocorticoid, to a client diagnosed with a primary brain tumor? 1. Decadron will prevent metastasis to other parts of the body. 2. Decadron is a potent anticonvulsant and will prevent seizures. 3. Decadron increases the uptake of serotonin in the brain tissues. 4. Decadron decreases intracranial pressure by decreasing inflammation.

Primary brain tumors rarely metastasize outside of the cranium because they kill by occupying space and increasing intracra- nial pressure. Decadron is not an anticonvulsant; it may decrease the chance of seizures by decreas- ing intracranial pressure, but the client may still have a seizure while taking Decadron. Decadron does not affect the uptake of serotonin. ✅4. Decadron decreases the inflammatory response of tissues. It is particularly used for edema (swelling) of the brain tissues. Comprehensive Examination. Pharmacology Success

81. The emergency department nurse received a client on warfarin (Coumadin) who has an International Normalized Ratio (INR) of 1.5. Which intervention should the nurse implement? 1. Prepare to administer protamine sulfate, an antidote. 2. Document the laboratory result and take no action. 3. Prepare to administer AquaMEPHYTON (vitamin K). 4. Notify the client's health-care provider.

Protamine sulfate is the antidote for he- parin toxicity. ✅2. The therapeutic range for INR is 2-3; therefore, the nurse should document the results and take no action. AquaMEPHYTON, vitamin K, is the anti- dote for Coumadin toxicity, which is sup- ported by an elevated INR greater than 3. The nurse does not need to notify the HCP for a normal laboratory value. Comprehensive Examination. Pharmacology Success

88. The nurse is preparing to administer the following medications. Which client should the nurse question administering the medication? 1. The client receiving prednisone, a glucocorticoid, who has a glucose level of 140 mg/dL. 2. The client receiving ceftriaxone (Rocephin), an antibiotic, who has a white blood cell count of 15,000. 3. The client receiving heparin, an anticoagulant, who has a PTT of 108 seconds with a control of 39. 4. The client receiving theophylline (Theo-Dur) who has a theophylline level of 12 mg/dL.

Steroids increase insulin resistance; this would be an expected effect of the pred- nisone. The nurse would not question administering this medication. This WBC is elevated and indicates an in- fection. Antibiotics are administered for bacterial infections. The nurse would not question administering this medication. ✅3. The therapeutic range for this control would be 59-78 seconds. This is an ex- tremely high PTT level, and the client is at risk for bleeding. The heparin should be discontinued immediately. The nurse would question this medication. This theophylline level is in the therapeutic range (10-20 mg/dL); the nurse would not question administering this medication. Comprehensive Examination. Pharmacology Success

Question in ASk me 3

The Ask Me 3 is an educational program intended to promote understanding and improve communication between patients and their providers ❑What is my main problem? ❑What do I need to do? ❑Why is it important for me to do this? Use of Ask Me 3 encourages patients and families to ask three specific questions of their health care providers during every encounter, to better understand their health conditions and what they need to do to stay healthy. Providers are encouraged to answer these questions in a clear, forthright manner. The Ask Me 3 questions are:

87. Which assessment data best indicates the client with reactive airway disease has not achieved "good" control with the medication regimen? 1. The client's peak expiratory flow rate (PEFR) is greater than 80% of his or her personal best. 2. The client's lung sounds are clear bilaterally both anteriorly and posteriorly. 3. The client has only had three acute exacerbations of asthma in the past month. 4. The client's monthly serum theophylline level is 18 μg/mL.

The PEFR is defined as the maximal rate of air flow during expiration; it can be measured with a relatively inexpensive, handheld device. If the peak flow is less than 80% of the client's personal best, more frequent monitoring should be done. The PEFR should be measured every morning. A normal respiratory assessment does not indicate that the medication regimen is effective and has "good" or "bad" control. ✅3.Three asthma attacks in the past month would not indicate the client has "good" control of the reactive airway disease. A serum theophylline level between 10 and 20 μg/mL indicates the medication is within the therapeutic range, but it is not the best indicator of the client's control of the signs or symptoms Comprehensive Examination. Pharmacology Success

36. The client with a severe acute exacerbation of Crohn's disease is prescribed total parenteral nutrition (TPN). Which interventions should the nurse implement when administering TPN? Select all that apply. 1. Monitor the client's glucose level daily. 2. Administer the TPN via an intravenous pump. 3. Assess the subclavian line insertion site. 4. Check the TPN according to the five rights prior to administering. 5. Encourage the client to eat all of the food offered at meals.

The TPN is 50% dextrose; therefore, the client's blood glucose level should be checked every 6 hours and sliding-scale insulin coverage should be ordered. ✅2. TPN should always be administered using an intravenous pump and not left to run by gravity; fluid volume and increased glucose resulting from an overload of TPN could cause a life- threatening fluid-volume or hyper- glycemic crisis. ✅3. TPN must be administered via a sub- clavian line, and any infection may lead to endocarditis; therefore, the nurse should assess the site. ✅4. TPN is considered a medication and should be administered as any other medication. The client with severe acute exacerbation of Crohn's is NPO to rest the bowel. When a client is on TPN he or she is usu- ally NPO because the TPN provides all necessary nutrients; therefore, the nurse would not encourage the client to eat food Comprehensive Examination. Pharmacology Success

73. The unlicensed assistive personnel (UAP) is making rounds and notices that the primary nurse left a medication cup with three tablets at the client's bedside. Which action should the UAP implement? 1. Administer the client's medications. 2. Remove the medication cup from the room. 3. Request the primary nurse come to the room. 4. Leave the cup at the bedside and do nothing.

The UAP cannot administer medications, and the medications should not be left at the bedside. Medication aides are permitted in some states to practice in long-term care facilities. This was not stated in the stem. Regardless, no one should adminis- ter a medication dispensed by another person ✅2 The UAP should take the medication cup back to the medication room and tell the primary nurse. Medications should never be left at the bedside. 3. The UAP nurse should not correct the primary nurse in front of the client; there- fore, this would not be an appropriate in- tervention. This is not in the realm of a UAP's duties. The person over the nurse is the one to confront the nurse. 4. The UAP is a vital part of the health-care team and is expected to maintain safety for the client. Comprehensive Examination. Pharmacology Success

65. The client who is coding is in asystole. Which intervention should the nurse imple- ment first? 1. Prepare to defibrillate the client at 360 joules. 2. Prepare for synchronized cardioversion. 3. Prepare to administer atropine, intravenous push. 4. Prepare to administer amiodarone, an antidysrhythmic.

The client in asystole would not benefit from defibrillation because there is no heart activity; the client must have some heart activity (ventricular activity) for de- fibrillation to be successful. Synchronized cardioversion is used for new-onset atrial fibrillation or unstable ventricular tachycardia. ✅3.Atropine is the drug of choice for asys- tole because it decreases vagal stimula- tion and increases heart rate Amiodarone is administered in life- threatening ventricular dysrhythmias, not asystole.

30. The client diagnosed with coronary artery disease is prescribed atorvastatin (Lipitor), an HMG-CoA reductase inhibitor. Which statement by the client indicates the medication is effective? 1. "I really haven't changed my diet, but I am taking my medication every day." 2. "I am feeling good since my doctor told me my cholesterol level came down." 3. "I am swimming at the local pool about three times a week for 30 minutes." 4. "Since I have been taking this medication the swelling in my legs is better."

The client should adhere to a low-fat, low-cholesterol diet, but this does not indicate the medication is effective. ✅2. This medication is prescribed to help decrease the client's cholesterol level; therefore, this statement indicates it is effective. A sedentary lifestyle is a risk factor for developing atherosclerosis; therefore, exercising should be praised but it does not indicate the medication is effective. The medication is not administered to decrease edema; therefore, this statement does not indicate the medication is effective Comprehensive Examination. Pharmacology Success

47. The client who is postmenopausal is prescribed alendronate (Fosamax), a bisphos- phonate, to help prevent osteoporosis. Which information should the nurse discuss with the client? 1. Chew the tablet thoroughly before swallowing. 2. Eat a meal prior to taking the medication. 3. Take the medication at night before going to sleep. 4. Remain upright for 30 minutes after taking medication

The client should swallow the medication. The client should not crush, chew, or suck the medication. The medication should be taken on an empty stomach at least 30 minutes before eating or drinking any liquid. Foods and beverages greatly decrease the effect of Fosamax. The medication will irritate the stomach and esophagus if the client lies down; therefore, the medication should be taken when the client can remain upright at least 30 minutes. ✅4 Fosamax can be taken daily or weekly, but because of the high risk of esophageal complications if the client does not take Fosamax exactly as pre- scribed, most HCPs prescribe the medication to be taken once a week. The client must take the medication on an empty stomach and remain in an upright position for a minimum of 30 minutes. Comprehensive Examination. Pharmacology Success

100. The client diagnosed with Addison's disease is being discharged. Which statement indicates the client understands the medication discharge teaching? 1. "I will be sure to keep my dose of steroid constant and not vary." 2. "I may have to take two forms of steroids to remain healthy." 3. "It is normal to become weak and dizzy when taking this medication." 4. "I must take prophylactic antibiotics prior to getting my teeth cleaned."

The dose of corticosteroids may have to be increased during the stress of an infection or surgery; therefore, this statement indicates the client does not understand the discharge teaching. ✅2. This statement indicates the client un- derstands the discharge teaching. The client may be prescribed both mineral and glucocorticoid medications. If the client gets weak or dizzy, it may indicate an underdosage of medication; therefore, this indicates the client does not understand the discharge teaching. The client does not have to take pro- phylactic antibiotics prior to invasive procedures. Comprehensive Examination. Pharmacology Success

40. The nurse is administering Humalog, a fast-acting insulin, at 0730 to a client diag- nosed with Type 1 diabetes. Which intervention should the nurse implement? 1. Ensure the client eats at least 90% of the food on the lunch tray. 2. Do not administer unless the breakfast tray is in the client's room. 3. Check the client's blood glucose level 1 hour after receiving insulin. 4. Have 50% dextrose in water at the bedside for emergency use.

The insulin will not be working 4-5 hours after being administered. ✅2. This insulin peaks in 15-20 minutes after being administered; therefore, the meal should be at the bedside prior to administering this medication. The glucose level should be checked prior to meals, not after meals. This medication is administered when a client is unconscious secondary to hypo- glycemia and should not be kept at the bedside. Orange juice or some type of simple glucose should be kept at the bedside. Comprehensive Examination. Pharmacology Success

24. The nurse is administering digoxin (Lanoxin) 0.25 mg intravenous push medication to the client. Which interventions should the nurse implement? Select all that apply. 1. Administer the medication undiluted in a 1-mL syringe. 2. Check the client's serum potassium level. 3. Pinch off the intravenous tubing above the port. 4. Inject the medication over 5 minutes at a steady rate. 5. Explain that experiencing a yellow haze is an expected side effect

The medication should be diluted with normal saline to increase the longevity of the vein for intravenous medication and fluids. Diluting decreases the client's pain secondary to the IV push. A 5-mL or 10-mL amount allows the nurse to inject the medication over a 5-minute time frame with better control than a 0.5-mL amount. ✅2. Hypokalemia may potentiate digoxin toxicity; therefore, the nurse should check the client's potassium level. ✅3.The nurse should pinch off the tubing above the port to ensure that the med- ication flows into the client's vein and not upward into the IV tubing. ✅4. The medication should be injected slowly over 5 minutes (2 minutes for most IV medications, except for med- ications that act directly on the cardio- vascular system and narcotics) and at a steady rate because a rapid injection could cause speed shock. Speed shock is a sudden adverse physiological reac- tion secondary to an IVP medication wherein the client develops a flushed face, a headache, a tight feeling in the chest, an irregular pulse, loss of con- sciousness, and possible cardiac arrest. 5. A yellow haze along with nausea, vomit- ing, and anorexia are signs of digoxin toxi- city and should be reported to the HCP Comprehensive Examination. Pharmacology Success

23. The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? 1. The loop diuretic furosemide (Lasix) to the client with a serum potassium level of 4.2 mEq/L. 2. The osmotic diuretic mannitol (Osmitrol) to the client with a serum osmolality of 280 mOsm/kg. 3. The cardiac glycoside digoxin (Lanoxin) to the client with a digoxin level of 1.2 mg/dL. 4. The anticonvulsant phenytoin (Dilantin) to the client with a phenytoin (Dilantin) level of 24 μg/mL

The normal serum potassium level is 3.5-4.5 mEq/L; therefore, the nurse would administer this medication. The normal serum osmolality is 275- 300 mOsm/kg; therefore, the nurse would administer this medication. The normal digoxin level is 0.8-2.0 mg/dL; a digoxin level of 1.2 mg/dL is within ther- apeutic range. The nurse would administer this medication. ✅4. The therapeutic serum level of Dilantin is 10-20 μg/mL; therefore, the nurse should question administering this medication. Comprehensive Examination. Pharmacology Success

96. The unlicensed assistive personnel (UAP) notified the primary nurse that the client is complaining of being jittery and nervous and is diaphoretic. The client is diagnosed with diabetes mellitus. Which interventions should the primary nurse implement first? 1. Have the UAP check the client's glucose level. 2. Tell the UAP to get the client some orange juice. 3. Check the client's Medication Administration Record. 4. Immediately go to the room and assess the client.

The nurse cannot delegate care of a client who is unstable, and hypoglycemia is a complication of treatment for diabetes mellitus. The treatment of choice for a client who is conscious and experiencing a hypo- glycemic reaction is to administer food or a source of glucose, but it is not the first intervention. Orange juice is a source of glucose and the UAP can get it. The nurse should check the MAR to de- termine when the last dose of insulin or oral hypoglycemic medication was admin- istered, but it is not the first intervention. ✅4. These are symptoms of a hypoglycemic reaction and the nurse should assess the client immediately; therefore, this is the first intervention Comprehensive Examination. Pharmacology Success

57. The client calls the nursing station and requests pain medication. When the nurse enters the room with the narcotic medication, the nurse finds the client laughing and talking with visitors. Which action should the nurse implement first? 1. Administer the client's prescribed pain medication. 2. Assess the client's perception of pain on a 1-10 scale. 3. Wait until the visitors leave to administer any medication. 4. Check the MAR to see if there is a nonnarcotic medication ordered.

The nurse should not administer pain med- ication until after assessing the client's pain. ✅2. The first action is always to assess the client in pain to determine if the client is having a complication that requires medical intervention rather than PRN pain medication. The nurse should assess the client, then administer the pain medication whether the client has visitors or not. The nurse should first assess the client's pain.

72. Which intervention should the nurse implement first when administering a tablet to the client? 1. Offer a glass of water to facilitate swallowing the medication. 2. Assess that the client is alert and has the ability to swallow. 3. Open the medication and place it in the medication cup. 4. Remain with the client until all medication is swallowed.

The nurse should offer water so that the client can swallow the medication, but it is not the first intervention. ✅2. The nurse should determine if the client can swallow the medication; this is the first intervention The nurse should check the medication against the Medication Administration Record, open the medication package, and place it in the medication cup at the bed- side, but this is not the first intervention. If the client cannot swallow or refuses the medication, the medication can be sent back to the pharmacy if it has not been taken out of the package. The nurse should remain with the client until the medication is swallowed. Comprehensive Examination. Pharmacology Success

85. The nurse is preparing to administer medications to the following clients. Which client should the nurse question administering the medication? 1. The client receiving the angiotensin receptor blocker losartan (Cozaar) who has a B/P of 168/94. 2. The client receiving the calcium channel blocker diltiazem (Cardizem) who has 2+ pitting edema. 3. The client receiving the alpha blocker terazosin (Hytrin) who has a regular apical pulse of 56. 4. The client receiving the thiazide diuretic hydrochlorothiazide (HCTZ), who is complaining of a headache.

The nurse would want to give this anti- hypertensive medication to a client with an elevated blood pressure; the nurse would question the medication if the B/P was low. The client with 2+ pitting edema would not be affected by a calcium channel blocker. ✅3. The nurse should question this med- ication if the apical rate is less than 60. A headache is not an adverse effect of HCTZ; therefore, the nurse would not question administering this medication Comprehensive Examination. Pharmacology Success

63. The nurse has administered an ophthalmic medication to the client. Which area should the nurse hold pressure to prevent systemic absorption? A. Outer canthus B. under the eyelid C. lower conjunctival sac D. Inner canthus/ lacrimal duct

The outer canthus does not have access to the systemic system; therefore, the nurse would not hold pressure in this area. The nurse should not hold pressure under the eyelid because the medication will not be retained in the eye. The nurse cannot hold pressure in the lower conjunctival sac because this would be painful for the client and would not prevent systemic absorption of the medication. ✅4. The lacrimal duct is located in the in- ner canthus area, and systemic absorp- tion of the medication can occur if the nurse does not apply light pressure to the area.

45. The male client is diagnosed with herpes simplex 2 viral infection and is prescribed valacyclovir (Valtrex). Which information should the nurse teach? 1. The medication will dry the lesions within a day or two. 2. Valtrex is taken once a day to control outbreaks. 3. The use of condoms will increase the spread of the herpes. 4. After the lesions are gone, the client will not transmit the virus

The time period for the lesions to heal depends on several factors, including the immune status of the individual who is infected and the amount of stress the indi- vidual is experiencing at the time. It usu- ally requires several days to more than a week for an outbreak to be healed. ✅2. Suppressive therapy with Valtrex is once daily, every day. This is an advan- tage of Valtrex over other antiretroviral medications, which require twice-a-day dosing. The use of condoms may prevent the spread of herpes infections; it does not in- crease the spread of the virus. It is possible to transmit the virus to a sex- ual partner with no visible signs of a lesion being present. Valtrex will not absolutely prevent the spread of the virus. It will treat an outbreak and decrease the risk of transmission. Comprehensive Examination. Pharmacology Success

49. The client is prescribed methotrexate (Rheumatrex), an antineoplastic agent, for pso- riasis. Which intervention should the nurse teach the client? 1. Teach the client that the urine may turn a red-orange color. 2. Have the client drink Ensure to increase nutritional status. 3. Tell the client to notify the HCP if a fever develops. 4. Encourage the client to increase green, leafy vegetables in the diet

The urine does not change color when the client takes methotrexate. The client should be encouraged to eat a balanced diet; drinking a supplement is not necessary. ✅3 Methotrexate suppresses the bone mar- row, resulting in decreased numbers of white blood cells; the client should notify the HCP if a fever develops because this could indicate an infection. There is no reason to increase the amount of green, leafy vegetables consumed when taking this medication. Comprehensive Examination. Pharmacology Success

34. Which data indicates the antibiotic therapy has been successful for a client diagnosed with a bacterial pneumonia? 1. The client's hematocrit is 45%. 2. The client is expectorating thick green sputum. 3. The client's lung sounds are clear to auscultation. 4. The client has complaints of pleuritic chest pain.

This hematocrit is normal but does not indicate that the client is responding to the antibiotics. Thick green sputum is a symptom of pneumonia, which indicates the antibiotic therapy is not effective. If the sputum were changing from a thick green sputum to a thinner, lighter-colored sputum, it would indicate an improvement in the condition. ✅3.The symptoms of pneumonia include crackles and wheezing in the lung fields. Clear lung sounds indicate an improvement in the pneumonia and that the medication is effective. Pleuritic chest is a symptom of pneumonia and does not indicate the medication is effective. Lack of symptoms indicates the medication is effective. Comprehensive Examination. Pharmacology Success

31. The nurse is preparing to administer medications on a pulmonary unit. Which medication should the nurse administer first? 1. Prednisone, a glucocorticoid, for a client diagnosed with chronic bronchitis. 2. Ceftriaxone (Rocephin), an intravenous antibiotic, an initial dose (ID). 3. Lactic acidophilus (Lactinex) to a client receiving IVPB antibiotics. 4. Cephalexin (Keflex) PO, an antibiotic, to a client being discharged.

This is an oral preparation and one that can be given daily; this is not the first medication to be administered. ✅2. An initial dose of intravenous antibiotic is priority because the client must be started on the medication as soon as possible to prevent the client from becoming septic. Lactinex is administered to replace the good bacteria in the body destroyed by the antibiotic, but it does not need to be administered first. Keflex is an oral antibiotic, but this client is being discharged, indicating the client's condition has improved. This client could wait until the initial dose of an IV antibi- otic is administered Comprehensive Examination. Pharmacology Success

37. The client is prescribed a stool softener. Which statement best describes the scientific rationale for administering this medication? 1. The medication acts by lubricating the stool and the colon mucosa. 2. Stool softeners irritate the bowel to increase peristalsis. 3. The medication causes more water and fat to be absorbed into the stool. 4. Stool softeners absorb water, which adds size to the fecal mass.

This is the rationale for administering mineral oil. This is the rationale for administering stimulants. ✅3. Stool softeners or surfactants have a detergent action to reduce surface tension, permitting water and fats to penetrate and soften the stool. This is the rationale for bulk-forming agents Comprehensive Examination. Pharmacology Success

95. The elderly male client diagnosed with diverticulosis tells the nurse he takes bisacodyl (Dulcolax), a stimulant laxative, daily. Which teaching is most important for the nurse to provide the client? 1. "It is not necessary for you to have a bowel movement every day." 2. "You need to increase fluids to prevent dehydration when taking this medication." 3. "You should use a bulk laxative when taking laxatives daily." 4. "You will need to increase the dose of laxative if you do not get good results."

This is true, but the client is using stimu- lant laxatives on a daily basis. This is not the most important teaching. Fluids are increased when taking bulk lax- atives so that fluid is available to increase the volume of stool. ✅3. If the client insists on taking a laxative daily, it should be a bulk-forming laxa- tive such as Metamucil. This type of laxative encourages the bowel to per- form its normal job and will not harm the integrity of the bowel. Stimulant laxative use over time causes a narrow- ing of the lumen of the bowel and will increase the likelihood of obstipation and bowel obstruction. Increasing the amount of stimulant laxa- tive will increase the potential for serious complications related to laxative abuse Comprehensive Examination. Pharmacology Success

Question 6 of 13 Bedside (point-of-care) computers are an example of informatics used in health care primarily for which purpose? Enhancing collaboration and coordination of care Offering clients access to email and the Internet Documenting interprofessional care Retrieving data for evidence-based practice

✅ Documenting interprofessional care The largest application of health care informatics is the growing trend of the use of electronic medical records (EMRs) for documenting interprofessional care. Computers may be located at the client's bedside or in a central area for ease of access for documentation. Computers allow quick communication among health care professionals to enhance collaboration and coordination of care; however, this type of communication typically would not take place at the client's bedside. Bedside computers in the health care setting are not intended for client use. The Internet provides ways to search multiple sources of information and retrieve data efficiently; however, this would not be done at the client's bedside. Enhancing collaboration and coordination of care The largest application of health care informatics is the growing trend of the use of electronic medical records (EMRs) for documenting interprofessional care. Computers may be located at the client's bedside or in a central area for ease of access for documentation. Computers allow quick communication among health care professionals to enhance collaboration and coordination of care; however, this type of communication typically would not take place at the client's bedside. Bedside computers in the health care setting are not intended for client use. The Internet provides ways to search multiple sources of information and retrieve data efficiently; however, this would not be done at the client's bedside. Offering clients access to email and the Internet The largest application of health care informatics is the growing trend of the use of electronic medical records (EMRs) for documenting interprofessional care. Computers may be located at the client's bedside or in a central area for ease of access for documentation. Computers allow quick communication among health care professionals to enhance collaboration and coordination of care; however, this type of communication typically would not take place at the client's bedside. Bedside computers in the health care setting are not intended for client use. The Internet provides ways to search multiple sources of information and retrieve data efficiently; however, this would not be done at the client's bedside. Retrieving data for evidence-based practice The largest application of health care informatics is the growing trend of the use of electronic medical records (EMRs) for documenting interprofessional care. Computers may be located at the client's bedside or in a central area for ease of access for documentation. Computers allow quick communication among health care professionals to enhance collaboration and coordination of care; however, this type of communication typically would not take place at the client's bedside. Bedside computers in the health care setting are not intended for client use. The Internet provides ways to search multiple sources of information and retrieve data efficiently; however, this would not be done at the client's bedside. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

Question 4 of 13 As a result of work completed by a quality improvement (QI) team, a new nursing protocol for preventing catheter-associated urinary tract infections (CAUTIs) is piloted. Which step of the PDSA QI model is associated with this action? P D S A

✅ S P stands for Plan, D stands for Do, S stands for Study, and A stands for Act. Piloting a new protocol would occur during the S step so that the QI team could test it for effectiveness before adopting it as standard policy. P P stands for Plan, D stands for Do, S stands for Study, and A stands for Act. Piloting a new protocol would occur during the S step so that the QI team could test it for effectiveness before adopting it as standard policy. D P stands for Plan, D stands for Do, S stands for Study, and A stands for Act. Piloting a new protocol would occur during the S step so that the QI team could test it for effectiveness before adopting it as standard policy. A P stands for Plan, D stands for Do, S stands for Study, and A stands for Act. Piloting a new protocol would occur during the S step so that the QI team could test it for effectiveness before adopting it as standard policy. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

Question 5 of 13 The nurse supports the client and family in deciding on a "Do Not Resuscitate" order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation? Legality Beneficence Self-determination Justice

✅ Self-determination Self-determination refers to the idea that clients are autonomous individuals capable of making informed decisions about their care. When the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate in the professional scope of practice. Beneficence emphasizes the importance of preventing harm and ensuring the client's well-being. Justice refers to equality (i.e., all clients should be treated equally and fairly). Legality is not one of the ethical principles. Legality Self-determination refers to the idea that clients are autonomous individuals capable of making informed decisions about their care. When the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate in the professional scope of practice. Beneficence emphasizes the importance of preventing harm and ensuring the client's well-being. Justice refers to equality (i.e., all clients should be treated equally and fairly). Legality is not one of the ethical principles. Beneficence Self-determination refers to the idea that clients are autonomous individuals capable of making informed decisions about their care. When the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate in the professional scope of practice. Beneficence emphasizes the importance of preventing harm and ensuring the client's well-being. Justice refers to equality (i.e., all clients should be treated equally and fairly). Legality is not one of the ethical principles. Justice Self-determination refers to the idea that clients are autonomous individuals capable of making informed decisions about their care. When the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate in the professional scope of practice. Beneficence emphasizes the importance of preventing harm and ensuring the client's well-being. Justice refers to equality (i.e., all clients should be treated equally and fairly). Legality is not one of the ethical principles. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

76. Which discharge instructions should the emergency department (ED) nurse discuss with the client who sustained a concussion and is being discharged home? Select all that apply. 1. Instruct the client to take acetaminophen (Tylenol) for a headache. 2. Tell the client to stay on a clear liquid diet for the next 24 hours. 3. Instruct the client to take one hydrocodone (Vicodin) for pain. 4. Tell the client to return to the ED if experiencing nausea and vomiting. 5. Recommend the client take aspirin for any physical discomfort.

✅ 1. The client can take nonnarcotic anal- gesics if experiencing a headache, and Tylenol would be appropriate to take for a headache. 2. The client can eat anything after experi- encing a concussion. 3. Narcotic analgesics should not be taken after a head injury because of further de- pression of the neurological status. 4. The client should not take aspirin because it may cause bleeding which could in- crease intracranial pressure. ✅5.Any nausea, vomiting (especially pro- jectile), or blurred vision could be in- creasing ICP; therefore, the client should return to the ED for further evaluation. Comprehensive Examination. Pharmacology Success

1. The client with cardiac disease is prescribed amiodarone (Cordarone), an antidys- rhythmic, orally. Which teaching intervention should the nurse implement? 1. Notify the health-care provider of dyspnea, fatigue, and cough. 2. Instruct the client to take the medication prior to going to bed. 3. Tell the client not to take the medication if the apical pulse is less than 60. 4. Explain that this medication may cause the stool to turn black.

✅ 1. These are adverse effects that would cause the HCP to discontinue this medication. This medication can cause pulmonary toxicity, which is progressive dyspnea, cough, fatigue, and pleu- ritic pain. 2. The medication can be taken at the client's convenience; the medication should be taken at the same time each day. 3. The client checks the radial pulse at home, not the apical pulse, which requires a stethoscope. 4. This medication does not cause the stool to turn black. Iron supplements make the client's stool turn black. Comprehensive Examination. Pharmacology Success

8. The client who has had abdominal surgery has an IV of Ringer's lactate infusing at 100 mL/hour. The nurse is hanging a new bag of fluid. Which rate should the nurse set the pump to infuse the Ringer's lactate? Answer

✅ 100 mL. The pump is set at the rate to be administered per hour; therefore, the nurse should set the rate at 100. Comprehensive Examination. Pharmacology Success

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? A. Call the legal department to draft the paperwork. B. Thank the adult child for sharing the parent's desires. C. Talk to the client to be sure of their wishes. D. Document the conversation in the electronic health record.

✅ C. Talk to the client to be sure of their wishes. The nurse would first talk to the client in order to determine the client's wishes and state of mind. As long as the client is lucid, he or she can articulate his or her own wishes regarding life support or the absence of such. Once the nurse has assessed that the client has certain end-of-life wishes, the nurse can confirm that the client wants these officially documented. If the client agrees, then the legal department can be contacted. Finally, the nurse can thank the adult child for sharing that the client has thoughts about life support, as this was the catalyst that allowed the nurse to further assess the client's wishes. The nurse could not act on the adult child's indications alone.

A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin (Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose? mL

✅ x = 2.5 mL In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the milliliters of gentamicin that should be added to the 0.9% sodium chloride solution. This item requires critical thinking because you have to analyze the dose on hand, convert the patient's weight to kilograms, and determine the dosage. Then you have to select the formula, enter data into the formula, and perform the needed calculations. STEP 1: Determine the client's weight in kg. 2.2 lb / x kg = weight in lb / 1 kg; 2.2 lb / x kg = 132 lb / 1 kg. Cross multiply and solve for x; 132 ÷ 2.2 = x; x = 60 kg. STEP 2: Find total daily dose: Amount prescribed x kg weight (mg x kg) = total daily dose; 5 mg x 60 kg = 300 mg. Because the medication was prescribed as mg/kg/day, 300 mg is the total daily dose. STEP 3: Find the amount per dose: Total daily dose / number of doses prescribed per day = amount per dose; 300 mg / 3 doses = 100 mg. Because the medication is to be administered in 3 equal doses, 100 mg is the amount per dose. STEP 4: What is the dose needed? Dose needed = Desired; Desired = 100 mg STEP 5: What is the dose available? Dose available = Have; Have = 40 mg STEP 6: Do the units of measure need to be converted? No (mg = mg) STEP 7: What is the quantity of the dose available? Quantity = 1 mL STEP 8: Set up an equation using knowledge about basic equivalents. Desired x Quantity / Have = Amount to be given; 100 mg x 1 mL / 40 mg = x mL; x = 2.5 mL STEP 9: Reassess to determine if the amount to be given makes sense. If there are 40 mg in 1 mL and the prescribed dose is 100 mg, it makes sense to add 2.5 mL to the solution. The nurse should add 2.5 mL gentamicin/dose to the solution. NurseLogic Knowledge and Clinical Judgment Advanced

1 of 18 A client admitted to the hospital states, "Someone asked me to fill out an advance directive when I was admitted, but I was too stressed. What is that for?" How will the nurse respond? "You will need to see a lawyer to complete advance directives." "You need to complete that paperwork before admission." "Advance directives allow a client to convey health care wishes." "Advance directives are for those individuals who are critically ill."

✅"Advance directives allow a client to convey health care wishes." The nurse responds by stating that advanced directives allow a client to convey his or her wishes about health care. This best addresses the client's comments. Most advance directives are in place before the client becomes severely ill. Many Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good to do this. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

The nurse prepares to teach a client at risk for increased clotting about interventions to prevent clots. What health teaching would the nurse include? (Select all that apply.) Select all that apply. "Avoid prolonged periods of sitting." "Walk around frequently as much as you can." "Avoid crossing your legs when sitting." "Drink plenty of fluids, including water." "Seek smoking cessation programs if needed." "Report any unusual bleeding or bruising."

✅"Avoid prolonged periods of sitting." ✅"Walk around frequently as much as you can." ✅"Avoid crossing your legs when sitting." ✅"Drink plenty of fluids, including water." "Seek smoking cessation programs if needed." All of these actions are important to prevent venous stasis which can lead to deep vein thrombosis except for option B. Clients who have a decreased ability to clot would experience unusual bleeding and bruising. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety? "Enroll in a safe driving refresher course and avoid risky driving situations." "Continue to eat healthy foods, especially protein." "Walk 30 minutes three to five times a week." "Seek counseling for depression, because it is not a normal part of aging."

✅"Enroll in a safe driving refresher course and avoid risky driving situations." Safe driving refresher courses are one method to help older adults identify and manage these lifestyle choices. Motor vehicle crashes are the most common cause of injury-related death for those between 65 and 74 years of age. To promote health and safety, driving should be discontinued when vision, reflexes, or confidence begin to suffer. Eating healthy foods and exercise promote health but not safety. Encouraging good mental health promotes well-being but not safety. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further? "For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at least three times a week." "With less activity and exercise in my life these days, I should reduce my total calorie intake." "To keep my bowel movements regular, I try to eat some fresh fruits or vegetables each day." "Although I enjoy eating sweets and desserts, I need to balance them with healthier foods."

✅"For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at least three times a week." Fast food is a contributor to high carbohydrate and caloric intake in older adults. Because fast food is relatively inexpensive and convenient, this population tends to abuse it, thus gaining weight from unhealthy calories. Older adults do enjoy sweets and desserts because their taste acuity changes, but they still need to eat a variety of foods that are high in protein and vitamins, as well as with different textures and fiber content. Consuming fresh fruits and vegetables is characteristic of a healthy lifestyle in older adults; this practice will help keep bowel habits routine. As older adults begin to lead a more sedentary lifestyle, they need to decrease their caloric intake to match a diminished basal metabolic rate. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

Question 13 of 13 The nurse is interviewing a transgender client about sexual orientation, gender identity, and health care. Which questions are appropriate as part of the interview? (Select all that apply.) Select all that apply. "Have you disclosed your gender identity and sexual orientation to your primary health care provider?" "Do you have problems being accepted because you are different?" "If you have more than one sexual partner, how are you protecting both of you from infections?" "Do you have sex with men, women, both, or neither?" "Are you in a relationship with someone who lives with you?"

✅"Have you disclosed your gender identity and sexual orientation to your primary health care provider?" ✅"If you have more than one sexual partner, how "Do you have sex with men, women, both, or neither?" ✅"Are you in a relationship with someone who lives with you?" All of these questions are culturally sensitive and respectful to the client with the exception of option C. The nurse would not judge the client and assume that the client is having "problems." Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

A client in rehabilitation says, "This is too hard. My life will never be the same again!" What is the nurse's BEST response? "How did you handle challenges before you were injured?" "Why don't you try a relaxation exercise?" "Should I call a family member to help?" "You will be fine, don't worry so much."

✅"How did you handle challenges before you were injured?" The nurse's BEST response is to ask the client how challenges were handled before the injury. The nurse should assess the client's previous coping strategies and support systems so that they can be used during rehabilitation, if needed. This open-ended question allows the client to problem solve and explore plausible ways to cope. Besides being a "closed" question requiring a "yes-or-no" response, asking if a family member should be called could provide a supportive environment for the client, but would not build coping skills. Suggesting a relaxation exercise minimizes the client's current situation, and "why" questions are not therapeutic because they place the client in a defensive mode. Also, relaxation may be an option, but is one that has to be learned. Telling the client that he or she will be fine minimizes the client's current situation. Giving reassurances is not considered a therapeutic response; it closes communication Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? "I quit smoking 10 years ago." "I had a heart attack 4 months ago." "I take a multivitamin daily." "I drink a glass of wine a night."

✅"I had a heart attack 4 months ago." The statement by the client that he or she had a heart attack 4 months ago requires further investigation. Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems. The nurse will note that the client takes a multivitamin, but this is not of substantial risk. Moderate alcohol consumption is not considered high-risk behavior. A past history of smoking should be noted, but current or more recent smoking is of greater concern. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

The nurse reviews a routine discharge teaching plan on postoperative care with a client. Which client statement indicates that teaching about wound care has been effective? "The wound will completely heal in about 2 months." "I should remove the dressing if the wound is draining." "I may need to restrict my activities for several months." "Some bleeding from the incision is normal for several weeks."

✅"I may need to restrict my activities for several months." To protect the integrity of the wound, activities may need to be restricted. The wound is usually open to air for healing, but draining wounds need to be covered. Bleeding and serosanguineous drainage are not normal after 5 days. The length of time it takes for a wound to heal varies, which can be up to 2 years. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

A rehabilitation nurse is teaching the client with a spastic bladder to perform intermittent catheterizations. Which client statement indicates the need for further education? "Before I catheterize myself, I will try to urinate." "I will catch myself at 9 a.m. and 9 p.m." "I will use the Valsalva and Credé maneuvers before trying to urinate." "You can teach my son to help me with the catheterizations."

✅"I will catch myself at 9 a.m. and 9 p.m." The statement by the client that, "I will catch myself at 9 a m and 9 p.m.," indicates the need for further education. The client should not go beyond 8 hours between catheterizations. The time between catheterizations in this scenario is 12 hours. This concept needs to be reinforced to the client. The client with a spastic bladder must attempt to void before the catheterization is performed. The Valsalva and Credé maneuvers should be used to attempt voiding before self-catheterization in clients with spastic or flaccid bladders. If the client cannot catheterize him- or herself, a family member can be taught to do it. Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching? "I will be sure to use the nebulizer four times per day." "I can't use my cromolyn nebulizer for a sudden asthma attack." "It will be several weeks before I notice an improvement in my asthma." "I will use my cromolyn nebulizer before using my albuterol inhaler."

✅"I will use my cromolyn nebulizer before using my albuterol inhaler." In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client needs further teaching. You will learn more about negatively worded items in Module 4.This item requires foundational thinking because you have to recall knowledge to determine which of the client's statements about cromolyn was false. "I will use my cromolyn nebulizer before using my albuterol inhaler" is not a true statement and indicates a need for further teaching. Cromolyn is an inhalation agent used to reduce bronchial inflammation and for the prophylactic management of mild to moderate asthma. Education to the client about the medication should specifically include that it is not effective for quick relief, and that when administered routinely on a set schedule, both the frequency and intensity of asthma attacks is decreased. However, it is also important to note that cromolyn can reduce exercise-induced bronchospasms when administered 15 min prior to anticipated exertions. When both cromolyn and albuterol are prescribed, albuterol should be inhaled first to open the airways because is a bronchodilator. After waiting a few minutes, the cromolyn can then be inhaled and will reach further into the lungs because of the dilatory effects of albuterol. "I will be sure to use the nebulizer four times per day." In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client needs further teaching. You will learn more about negatively worded items in Module 4.This item requires foundational thinking because you have to recall knowledge to determine which of the client's statements about cromolyn was false. "I will be sure to use the nebulizer four times per day." is a true statement and does not indicate the need for further teaching. "I can't use my cromolyn nebulizer for a sudden asthma attack." In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client needs further teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge to determine which of the client's statements about cromolyn was false. "I can't use my cromolyn nebulizer for a sudden asthma attack." is a true statement and does not indicate a need for further teaching. Cromolyn has a slow onset and will not relieve an acute asthma attack. A fast-acting bronchodilator should be given if the client is experiencing an acute bronchospasm. "It will be several weeks before I notice an improvement in my asthma." In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client needs further teaching. You will learn more about negatively worded items in Module 4.This item requires foundational thinking because you have to recall knowledge to determine which of the client's statements about cromolyn was false. "It will be several weeks before I notice an improvement in my asthma." is a true statement and does not indicate a need for further teaching. Cromolyn is a prophylactic medication and the client will not feel the effects of it for several weeks; expecting otherwise can lead to noncompliance. Clients should be aware that taking cromolyn is necessary even though its effect is not immediately felt. NurseLogic Knowledge and Clinical Judgment Advanced

A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis? Tuberculin test Chest x-ray Enzyme-linked immunoassay (ELISA) test Sputum culture for acid-fast bacillus

✅Sputum culture for acid-fast bacillus In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis, which is an airborne organism. Once infected, the bacteria multiply freely after reaching the bronchi or alveoli. Typically, acquired immunity protects individuals from attaining active tuberculosis. Infection is most common among those who are immunocompromised and those who have been in repeated, close contact with someone who has an undiagnosed case of active tuberculosis. The lungs are primarily involved, but the infection can spread to other organs. Symptoms of pulmonary tuberculosis include productive cough, fever, fatigue, weight loss, hemoptysis, and night sweats. In cases of active pulmonary tuberculosis, the organism is transmitted through the air because it is found in the sputum and secretions. The presence of acid fast bacillus in the sputum, secretions, or tissues of the client is the only method to confirm the diagnosis of active tuberculosis. Tuberculin test In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. A positive tuberculin test indicates the client has been exposed to tuberculosis and has developed antibodies to the bacillus. While the tuberculin test is an effective screening tool, it is not helpful in distinguishing between an active case of tuberculosis and a client who was previously exposed to tuberculosis. This test does not confirm active pulmonary tuberculosis. Chest x-ray In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. A chest x-ray can be helpful for detecting old or new lesions that are large enough to be visualized; however, this test does not confirm a diagnosis of active pulmonary tuberculosis. Enzyme-linked immunoassay (ELISA) test In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. The ELISA is a rapid test where an antibody or antigen is linked to an enzyme as a means of detecting a match between the antibody and antigen, such as the ELISA screening test performed to detect whether or not a client is HIV positive. There is no serum ELISA test for tuberculosis; therefore, this test does not confirm a diagnosis of active tuberculosis.

A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements by the client indicates a need for further teaching? "I'll make sure that the medication container is kept tightly sealed." "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." "I'll keep my pills in the medicine cabinet when I'm home." "I'll go to the emergency room if my chest pain doesn't go away."

✅"I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." In this item, you need nursing knowledge related to the proper administration and storage of nitroglycerin. Based on an understanding of this information, you can identify which option describes a statement by the patient that does not reflect accurate understanding of the medication. This is a negatively worded item that asks you to select the option that indicates the patient needs further teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the administration and storage of nitroglycerin. This statement by the client indicates a need for further teaching. Buying nitroglycerin in bulk quantities is not a safe practice. The chemical instability of the medication allows it to lose effectiveness over time. While some nitroglycerin tablets have a shelf life of 24 months, NitroQuick retains its effectiveness for only 8 to 10 months. Because of the shortened shelf life, the client should not buy the medication in bulk quantities, and the client should be instructed to date the bottle when it is first opened. "I'll make sure that the medication container is kept tightly sealed." In this item, you need nursing knowledge related to the proper administration and storage of nitroglycerin. Based on an understanding of this information, you can identify which option describes a statement by the patient that does not reflect accurate understanding of the medication. This is a negatively worded item that asks you to select the option that indicates the patient needs further teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the administration and storage of nitroglycerin. This statement by the client does not indicate a need for further teaching. The client should keep the nitroglycerin tablets in a dark, dry place, and in a dark-colored glass bottle with a tight lid. Tablets lose potency in containers made of plastic or cardboard or when mixed with other capsules or tablets. "I'll keep my pills in the medicine cabinet when I'm home." In this item, you need nursing knowledge related to the proper administration and storage of nitroglycerin. Based on an understanding of this information, you can identify which option describes a statement by the patient that does not reflect accurate understanding of the medication. This is a negatively worded item that asks you to select the option that indicates the patient needs further teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the administration and storage of nitroglycerin. This statement by the client does not indicate a need for further teaching. The client knows to keep the medication in a dark, dry place because exposure to air, heat, and moisture cause loss of potency. "I'll go to the emergency room if my chest pain doesn't go away." In this item, you need nursing knowledge related to the proper administration and storage of nitroglycerin. Based on an understanding of this information, you can identify which option describes a statement by the patient that does not reflect accurate understanding of the medication. This is a negatively worded item that asks you to select the option that indicates the patient needs further teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the administration and storage of nitroglycerin. This statement by the client does not indicate a need for further teaching. Going to the emergency department for chest pain is a critical point that can save the client's life. The client should call 911 or go to the nearest emergency department if anginal pain is not relieved within 5 min. Typically, the client can take up to 2 additional nitroglycerin tablets at 5-min intervals while awaiting emergency care.

The nurse prepares a presentation on promoting a healthy gut at a health fair. Which information should the nurse include to prevent constipation? (Select all that apply.) Select all that apply. "Increase the amount of fresh fruits and vegetables in diet." "Do not ignore the urge to defecate." "Use over-the-counter laxatives frequently." "Decrease the amount of fiber in diet." "Maintain fluid intake of at least 2000 mL/day." "Establish a regular exercise routine."

✅"Increase the amount of fresh fruits and vegetables in diet." ✅"Do not ignore the urge to defecate." ✅"Maintain fluid intake of at least 2000 mL/day." ✅"Establish a regular exercise routine." In a discussion at a health fair about promoting a healthy gut and preventing constipation, the nurse would include advice about not ignoring the urge to defecate, establishing a regular exercise routine, and increasing the amount of fresh fruits and vegetables in the diet. Maintaining normal elimination requires adequate nutrition and hydration. People with, or at risk for, constipation should be taught to promptly toilet when the urge occurs, exercise to stimulate peristalsis, eat a diet high in fiber (found in fruits, vegetables, and whole grains) and to drink 8 to 12 glasses of water (2000 to 3000 mL) each day unless medically contraindicated. Fiber needs to be increased, not decreased. Also, clients with constipation may need to take bulk-forming agents or stool softeners in addition to a high-fiber diet and fluids. However, they do not need to take them regularly. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

The nurse is reinforcing the physical therapist's teaching on gait training for a client who had a total knee replacement 6 weeks ago. Which ambulatory aid does the nurse expect the client to be using? Walker with rollers Crutches Walker with a built-in seat Straight cane

✅Straight cane A straight cane is the most likely ambulatory aid for a client who is 6 weeks postsurgery from a knee replacement. The client should be weight bearing, with some assistance, on the affected leg. Crutches would have been used earlier in the rehabilitation process. Clients who need assistance with both weight bearing and balance would be using a walker, and specialized walkers with a seat (for resting) are especially helpful for clients who tire easily; no indication suggests that this client has those needs. Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

The nurse is instructing a client about the postoperative use of antiembolism stockings. Which statement by the client indicates the need for further teaching? (Select all that apply.) Select all that apply. "I will take off my stockings one to three times a day for 30 minutes." "It is up to me to determine how long I wear the stockings at each interval." "My stockings are loose so they do not hurt my legs." "These stockings help promote blood flow." "I feel like these stockings are compressing my legs just a bit."

✅"It is up to me to determine how long I wear the stockings at each interval." ✅"My stockings are loose so they do not hurt my legs." Stockings that are too loose are ineffective. Stockings that are too tight will impede blood flow. The client should wear the stockings as prescribed; not at their own discretion. Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Antiembolism stockings may be used during and after surgery to promote venous return. Antiembolism stockings should fit properly by providing gentle compression to achieve the desired result. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond? "Yes, this is a valuable way for all of you to make needed adjustments." "Let's ask your father about your request." "No, his pain relief is more important than your concerns." "I will ask his oncologist about your question."

✅"Let's ask your father about your request." The nurse will respond by indicating that the client's desires about analgesia are the most important consideration in this scenario, and so he would be consulted initially about his family's request. This open-ended type of question acknowledges the family, while keeping the client as the major decision maker. Although the health care provider might have an opinion about the family's request, pain is subjective, and the client's desires about analgesia are the most important consideration. Telling the family that the father's pain control is more important than their concerns is a demeaning response, although technically true; it is dismissive of the family and is nontherapeutic. Giving the family control of pain relief for their father is inappropriate in this situation; the subjective nature of pain places decisions about the use of analgesia with the client who is experiencing the pain. The family and the client may need to make adjustments, but reducing pain relief for the client is not an advisable way to accomplish this goal. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

17 of 19 The nurse is teaching the client about the use of medical marijuana. What teaching will the nurse include? (Select all that apply.) Select all that apply. "Medical cannabis is a controlled substance in the United States". "Federal and state law often vary in the legality of medical cannabis use." "The psychoactive component of medical cannabis is removed." "Your health care provider can prescribe cannabis for you." "Side effects of cannabis can include dizziness and increased appetite."

✅"Medical cannabis is a controlled substance in the United States". ✅"Federal and state law often vary in the legality of medical cannabis use." ✅"Side effects of cannabis can include dizziness and increased appetite. Cannabis is a schedule I controlled substance and has been since 1970. Federal and state law often vary in the legality of cannabis use. A health care provider cannot prescribe cannabis in any state; however, they may assess and determine whether a client has a qualifying condition in accordance with state law. Side effects of cannabis include: increased heart rate, increased appetite, dizziness, decreased blood pressure, dry mouth, hallucinations, paranoia, altered psychomotor function, and impaired attention. The psychoactive component, THC, is not removed from medical cannabis. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

An older adult client admitted to a nursing home for rehabilitation asks the nurse if the client's care will be covered by Medicare. What response by the nurse is correct? "Medicare A should cover 100% of your rehabilitation skilled care for a limited period of time." "Medicare D should pay for the total costs of drugs you take while you are here." "Medicare G should pay 80% of your lab and x-rays while you are here." "Medicare B should pay 100% of your rehabilitation therapy sessions while you are here."

✅"Medicare A should cover 100% of your rehabilitation skilled care for a limited period of time." Medicare A pays for skilled care in hospitals and other settings. However, the client must be certified as requiring skilled care requiring licensed health professionals to provide assessments and interventions for the client. The maximum limit for skilled care with 100% Medicare coverage is 100 days. Medicare B does not pay for 100% of therapy and Medicare D may not pay for the total costs of drugs. There is no Medicare G plan. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

A client with right-sided weakness is receiving antihypertensive medications. What does the RN communicate to the physical therapist (PT), who is planning to help the client walk? "Move the client from lying to standing slowly." "Monitor the client for weakness and fatigue during exercise." "Use a gait belt when ambulating the client." "Remind the client to use the left side to grip."

✅"Move the client from lying to standing slowly." The RN tells the PT to move the client from lying to standing slowly. Because the PT may not be aware of the client's medications or that antihypertensives can cause orthostatic hypotension, the nurse should discuss this with the PT before the client is ambulated. The PT will not need instruction about how to safely exercise (monitor for weakness), to use the left side to grip, or to ambulate the client, because these activities are included in the role of the PT in rehabilitation Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

The charge nurse is working with a new nurse. Which statement by the new nurse requires additional teaching by the charge nurse? "Older adults usually believe that pain is irrelevant and is to be expected." "Older adults are at a very high risk for undertreated pain." "Older adults typically believe that expressing pain is acceptable." "I always assess older adults for present pain."

✅"Older adults typically believe that expressing pain is acceptable." The charge nurse will need to provide further education to the new nurse regarding the statement, "Older adults typically believe that expressing pain is acceptable." Older adults typically do not believe that expressing pain is acceptable. Many older adults believe that pain is irrelevant and is "just part of getting older." As a result, many older adults are at great risk for undertreated pain. In addition, some health care providers have outdated beliefs about older adults' pain sensitivity, tolerance, and ability to take opioids. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction from the nurse? "I will have a bandage on my chest." "My family will not be able to see me right away." "I will wake up with a tube in my throat." "Pain medication will take away all of my pain."

✅"Pain medication will take away all of my pain." The client's statement that, "Pain medication will take away all of my pain," indicates the need for further instruction. Pain medication will reduce pain, but will not take it away completely. The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.

A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What will the nurse say to the visitor? "Please allow the client to push the button when needed." "Please don't touch any equipment in the client's room." "Thank you. I am sure the client appreciated that." "The client is asleep and is not in pain."

✅"Please allow the client to push the button when needed." The nurse will request that the visitor allow the client to push the button for medication when needed. The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues. Telling the family member not to touch any equipment in the client's room is not only nonspecific, but it may also be perceived as disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the client is asleep does not mean that the client is pain-free. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

An older adult client whose spouse died the previous year says to the nurse, "Life is not fun anymore." How does the nurse respond? "Why don't you go on a vacation? A change of scenery will do you good." "Are you getting enough sleep? That makes me feel better!" "How are you feeling about the death of your spouse after this length of time?" "Tell me about your support network, such as friends or family.

✅"Tell me about your support network, such as friends or family." Establishing and maintaining relationships with others throughout life is especially important to a person's happiness. Older adults who have close, intimate, and stable relationships with others in whom they can confide are more likely to cope with crises. Sleep can affect coping, but this is not the best answer, and is a closed-ended question not allowing for elaboration. The nurse providing information about "self" is also nontherapeutic. Asking about the spouse's death is leading, and the source of the client's statement may have nothing to do with the spouse's death. Suggesting a vacation does not address the issue at hand. "Why" questions are typically nontherapeutic and often place clients in a defensive stance. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate? "Clients having this surgery are always scared." "Why have you changed your mind about the surgery?" "You shouldn't worry, everything will be fine." "Tell me more about your concerns."

✅"Tell me more about your concerns." In this item, you need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Giving a general lead encourages the client to openly share feelings and concerns in a non-threatening environment, which will assist in establishing a meaningful nurse-client relationship. This response by the nurse is appropriate and fosters the nurse-client relationship. "Clients having this surgery are always scared." In this item, you need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Sharing generalized beliefs is an automatic response and can result in the client feeling belittled or that her concerns are not being taken seriously. This response by the nurse is not appropriate and threatens the nurse-client relationship. "Why have you changed your mind about the surgery?" In this item, you need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Beginning a question with "why" or requesting an explanation from the client can lead to resentment, mistrust, and insecurity. This response by the nurse is not appropriate and threatens the nurse-client relationship. "You shouldn't worry, everything will be fine." In this item, you need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Offering false reassurance is an attempt to avoid the client's concerns and discourages additional discussions, resulting in a communication block. This response by the nurse is not appropriate and threatens the nurse-client relationship. NurseLogic Knowledge and Clinical Judgment Beginner

A 44-year-old client with osteoarthritis pain tells the nurse, "I take two extra-strength acetaminophen (500 mg) every 8 hours." How does the nurse respond? "More acetaminophen is needed to provide effective pain relief for you." "You will need to have routine blood draws to monitor clotting time." "That is the appropriate dose of acetaminophen for your pain." "Aspirin would be a better, more effective choice for your pain relief."

✅"That is the appropriate dose of acetaminophen for your pain." In the healthy adult, a maximum daily dose below 4000 mg is rarely associated with liver toxicity. Many experts recommend reducing the daily dose (e.g., 2500 to 3000 mg daily) when used for long-term treatment in older adults. Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice for many people in pain, especially older adults. The dose is appropriate; more is not indicated or advised. Acetaminophen is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." Which nursing response is appropriate? "I will discuss cancelling your medication order with your health care provider." "That sounds like a wonderful idea; and I think it will definitely work!" "That sounds like a great plan; can you tell me more about it?" "Your plan will not work; people with your type of pain need opioids."

✅"That sounds like a great plan; can you tell me more about it?" Complementary and integrative therapies are most often used to supplement, not replace, medication management. The nurse needs to obtain more data, and will ask for more information about the client's plan. Contacting the health care provider to cancel the medication order is not appropriate. Telling the client that his idea is wonderful and will definitely work is not appropriate, as alternative strategies alone, may not work to relieve the client's pain. Telling the client that his or her plan will not work is dismissive of the client. In addition, the client may not need to be prescribed opioids for the pain Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

Question 5 of 15 The nurse is evaluating factors that influence care for a client with diabetes. Which client statement does the nurse identify that reflects a social determinant of health? A."The grocery store in my neighborhood went out of business." B. "The landlord of my apartment is putting in an access ramp for wheelchairs." C. "I work with a lot of toxic chemicals in my job." D. "Because I live on the bus line, I can ride over to park if I want to get fresh air."

✅"The grocery store in my neighborhood went out of business." Social determinants of health include availability of resource to meet daily needs, such as healthful foods. Physical determinants of health include physical barriers or access (such as an access ramp), exposure to toxic substances and other physical hazards, and access to worksites, schools, and recreational settings. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

A recently injured client who is paraplegic is in rehabilitation. Which client comment indicates that he or she is adapting to new self-care activities? "I don't want to do this today." "My dog can do this—why can't I do it too?" "I am so tired today, I want to rest." "This isn't working; I need to try something else."

✅"This isn't working; I need to try something else." The client's comment that he or she needs to try something else indicates an overall willingness to try on the client's part. When one method failed, the client was motivated to try something else. The comment that the client wants to rest can be indicative of depression; the client is not trying to do "more" but rather "less." Not wanting "to do this today" can be indicative of depression or denial; the client is not even making an effort to engage in self-care. Saying that "my dog can do this" exhibits extreme frustration; the client sounds angry, which should be explored to be better understood Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

3 of 18 The family of a client who is unconscious and dying realizes that their mother will die soon. The client's children are having a difficult time letting go. How will the nurse respond to the needs of this family? "She will soon be in a better place." "She would not want you to cry; she needs you to be strong." "This must be difficult for you." "Things will be ok, just try to enjoy your time together."

✅"This must be difficult for you." The nurse responds by stating, "This must be difficult for you." This statement tells the family that the nurse is aware of their needs. The nurse knows that she must accept whatever the grieving person says about the situation, must remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss. The client's or family member's pain of loss should never be minimized. Trite assurances such as saying, "She would not want you to cry" or "Things will be ok," should be avoided. Such comments can actually be barriers to demonstrating care and concern. Never try to explain a client's death or impending death in philosophic or religious terms because such statements are not helpful when the bereaved person has yet to express feelings of anguish or anger. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

The nurse is teaching a health and wellness class at a local senior citizen center. When discussing methods to promote cognition, which options would be included? (Select all that apply.) Select all that apply. Take music lessons. Watch television. Read the newspaper. Complete crossword puzzles. Play card games. Learn a new language

✅Take music lessons. ✅Complete crossword puzzles. ✅Learn a new language Methods to promote cognition include encouraging senior citizens to stimulate the intellectual part of their brain through new learning activities such as taking music lessons, mastering a new language, or completing crossword puzzles or other "brain teasers." Playing cards, reading the newspaper, and watching television are not new learning activities that could stimulate the intellectual part of the brain. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

A nurse is caring for a client who has a new colostomy. The client is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughter states that she doesn't know how she is going to care for her mother's colostomy? "It's quite simple. I'll make sure that her colostomy bag is clean before she leaves and you'll have no problems." "Is the colostomy care the only reason your mother is going to be living with you?" "A home health nurse will be stopping by tomorrow. If you have any questions, you can ask her." "What part of your mother's care concerns you?"

✅"What part of your mother's care concerns you?" In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Clarification encourages the other person to further express concerns so they can be addressed. This is an appropriate response by the nurse because it uses the communication tool of clarification. "It's quite simple. I'll make sure that her colostomy bag is clean before she leaves and you'll have no problems." In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. False reassurance is often an attempt by the nurse to avoid dealing with the other person's concerns and discourages further discussion of feelings. This is not an appropriate response by the nurse because it uses the communication block of false reassurance. "Is the colostomy care the only reason your mother is going to be living with you?" MY ANSWER In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. Asking personal questions typically does not yield information that is relevant to the situation and does not exemplify professional communication. This is not an appropriate response by the nurse because it uses the communication block of asking personal questions. "A home health nurse will be stopping by tomorrow. If you have any questions, you can ask her." In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. Passive responses tend to put the other person's concerns on hold, or sidestep the issue. In this scenario, the nurse is placing the responsibility for addressing the daughter's concerns on the home health nurse. This is not an appropriate response by the nurse because it uses the communication block of passiveness. NurseLogic Knowledge and Clinical Judgment Advanced

The nurse is assessing a client for acute or persistent pain. What nursing question allows the nurse to obtain the most data from the client? "Is the pain really that bad?" "Does it feel like sharp pain?" "When does the pain occur?" "Did someone do this to you?"

✅"When does the pain occur?" Asking when the pain occurs helps determine precipitating factors to identify the source of pain. It is an open-ended question that requires a descriptive response and allows the nurse to obtain the most data. Asking if someone hurt the client may be appropriate in rare circumstances, but typically it is not an appropriately focused question; the question does not relate to the severity or character of the pain. Further, this is not an open-ended question. The nurse should ask the client open-ended questions, not questions requiring a "yes-or-no" answer, such as "Does it feel like sharp pain?" Asking "Is the pain really that bad?" minimizes the client's perception of pain; it is also a closed-ended question requiring a "yes-or-no" answer. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

4 of 18 The daughter of a client who is dying states, "I don't want my father to be uncomfortable." How will the nurse respond? "Your father will be closely monitored and cared for." "Do you want to talk to the bereavement nurse?" "Your father will be sedated and comfortable." "We will send him to hospice when the time comes."

✅"Your father will be closely monitored and cared for." The nurse responds by telling the daughter that her father will be closely monitored and cared for. This would reassure the daughter as well as providing support and comfort. The daughter's comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a "yes-or-no" question, it is a nontherapeutic response and may shut off the dialog. The client who is dying is not typically kept sedated; clients are kept comfortable with as little or as much pain medication as needed. A goal is to keep the client alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter's concern about her father's comfort and it closes the dialog. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). Which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy? 0.25 mEq/L 0.75 mEq/L 1.5 mEq/L 2.25 mEq/L

✅0.75 mEq/L To answer this item, you need knowledge of therapeutic serum lithium level levels. Based on your understanding of this information, you can select the option with the serum lithium level appropriate for maintenance therapy. This item requires foundational thinking because you have to recall knowledge of therapeutic serum lithium levels. Lithium is a mood-stabilizing medication used in the treatment of bipolar I acute and recurrent manic and depressive episodes. To achieve a therapeutic range, give 300 mg to 600 mg of lithium during the active phase. The therapeutic serum lithium level is between 0.8 mEq/L and 1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are prescribed lithium for long-term therapy. Because small increments of dosage separate therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for maintenance therapy. NurseLogic Knowledge and Clinical Judgment Advanced

35. Which statement is the scientific rationale for administering an antacid to a client diagnosed with gastrointestinal reflux disease (GERD)? 1. Antacids neutralize the gastric secretions. 2. Antacids block H2 receptors on the parietal cells. 3. Antacids inhibit the enzyme that generates gastric acid. 4. Antacids form a protective barrier against acid and pepsin

✅1 This is the mechanism of action for antacids. This is the mechanism of action for hista- mine2 blockers. This is the mechanism of action for proton- pump inhibitors. This is the mechanism of action for mucosal barrier agents. Comprehensive Examination. Pharmacology Success

50. With which client should the nurse use caution when applying mafenide acetate (Sul- famylon), a topical antimicrobial agent, to a burned area? 1. A client with a creatinine level of 2.8 mg/dL. 2. A client with congestive heart failure. 3. A client with a pulse oximeter reading of 95%. 4. A client with diabetes Type 2 taking insulin.

✅1 This medication affects the acid-base balance in the body and should not be administered to clients with renal dis- ease. A 2.8 mg/dL serum creatinine level indicates renal insufficiency; therefore, the nurse would use caution with this client. Clients with congestive heart failure would not be affected by this medication. This client has adequate respiratory status; therefore, the nurse would not need to use caution with this client. There is no reason a client with diabetes could not be prescribed mafenide acetate Comprehensive Examination. Pharmacology Success

61. The 8-year-old child newly diagnosed with attention deficit-hyperactivity disorder (ADHD) is prescribed methylphenidate (Ritalin), a central nervous stimulant. Which statement by the mother indicates the medication teaching is effective? 1. "I will keep the medication in a safe place." 2. "I will give my child this medication every 12 hours." 3. "It may cause my child to have growth spurts." 4. "My child will probably experience insomnia."

✅1. All medication must be kept in a safe place to prevent accidental poisoning of children. 2. The last medication should be adminis- tered no later than 1400 in the afternoon or the child will not be able to sleep at night. Ritalin is a stimulant. This state- ment indicates the mother does not un- derstand the medication teaching. 3. Growth rate may be stalled in response to nutritional deficiency caused by anorexia; it does not cause growth spurts. This statement indicates the mother does not understand the medication teaching. 4. Insomnia is an adverse reaction to the medication; central nervous stimulants may disrupt normal sleep patterns. This statement indicates the medication teach- ing has not been effective Comprehensive Examination. Pharmacology Success

78. Which information should the nurse teach the client and family of a client prescribed donepezil (Aricept), a cholinesterase inhibitor? 1. Aricept may delay the progression of Alzheimer's for 6 months to a year. 2. Aricept will repair the brain damage in clients with Alzheimer's. 3. Aricept is still experimental as far as how it works to treat Alzheimer's. 4. Aricept is difficult for clients to tolerate because of the many side effects.

✅1. Aricept and other cholinesterase in- hibitors have shown the potential to delay the progression of Alzheimer's disease. The client and family should be told that, although it offers them hope, it only lasts for 6 months to a year. Aricept does not repair the brain tissue; there is no medication that repairs lost brain tissue. Aricept is not an experimental medication. Aricept works by preventing the break- down of acetylcholine (Ach) by acetyl- cholinesterase and thereby increases the availability of Ach at the cholinergic synapses. Aricept is the best tolerated of the cholinesterase inhibitors because it has fewer side effects. Comprehensive Examination. Pharmacology Success

21. Which is the scientific rationale for prescribing decongestants for a client with a cold? 1. Decongestants vasoconstrict the blood vessels, reducing nasal inflammation. 2. Decongestants decrease the immune system's response to a virus. 3. Decongestants activate viral receptors in the body's immune system. 4. Decongestants block the virus from binding to the epithelial cells of the nose

✅1. Decongestants vasoconstrict the blood vessels, resulting in decreased inflam- mation in the nasal passages. This vasoconstriction is the reason that OTC cold medications are labeled not to be used by clients diagnosed with hypertension and diabetes. 2. Decongestants do not decrease the im- mune system's response to the virus. 3. Activating viral receptors would increase the symptoms of a cold. 4. This is the rationale for zinc. Theoreti- cally, zinc blocks the virus from binding to nasal epithelium. Research has shown that increased amounts of zinc can prevent the binding and development of rhinovirus Comprehensive Examination. Pharmacology Success

43. The client in end-stage renal disease is receiving oral Kayexalate, a cation exchange resin. Which assessment data indicates the medication is not effective? 1. The client's serum potassium level is 5.8 mEq/L. 2. The client's serum sodium level is 135 mEq/L. 3. The client's serum potassium level is 4.2 mEq/L. 4. The client's serum sodium level is 147 mEq/L

✅1. Kayexalate is a medication that is admin- istered to decrease an elevated serum potassium level; therefore, an elevated serum potassium (5.5 mEq/L) would indicate the medication is not effective. Kayexalate is not used to alter the serum sodium level. Kayexalate is a medication that is adminis- tered to decrease an elevated serum potas- sium level; therefore, a potassium level within the normal range of 3.5-5.5 mEq/L indicates the medication is effective. Kayexalate is not used to alter the serum sodium level. Comprehensive Examination. Pharmacology Success

19. The charge nurse on an orthopedic unit is transcribing orders for a client diagnosed with back pain. Which HCP order should the charge nurse question? 1. Morphine sulfate, a narcotic analgesic, Q q 4 hours ATC. 2. CBC and CMP (complete metabolic panel). 3. Hydrocodone (Vicodin), an opioid analgesic, q 4 hours PRN. 4. Carisoprodol (Soma), a muscle relaxant, PO, b.i.d.

✅1. Morphine is a potent analgesic with addictive properties, and the nurse should question a routine administration of this medication. The HCP may have failed to write PRN after the order. 2. Many medications can affect the kidneys or the liver and the blood counts. Baseline data should be obtained. There is no reason to question this order. 3. This medication order is an appropriate order. The nurse would not question this order. 4. Soma comes in one strength, so this order is complete. There is no reason to ques- tion this order. Comprehensive Examination. Pharmacology Success

91. The nurse is administering 0800 medications. Which medication should the nurse question? 1. Ibuprofen (Motrin), a nonsteroidal anti-inflammatory drug, to a 49-year-old female with a peptic ulcer. 2. Omeprazole (Prilosec), a proton-pump inhibitor, to an 18-year-old male with a duodenal ulcer. 3. Digoxin (Lanoxin), a cardiotonic, to a 76-year-old male with a potassium level of 4.2 mEq/L. 4. Riopan, an antacid, to a 67-year-old client diagnosed with congestive heart failure who is complaining of indigestion

✅1. NSAIDs decrease prostaglandin and in- crease the client's risk for ulcer disease. They are contraindicated for use in clients diagnosed with ulcer disease. The nurse should question this medication. Prilosec is prescribed to treat duodenal and gastric ulcers; the nurse would not question this medication. Hypokalemia can increase digoxin toxicity. This potassium level is within normal range (3.5-5.5 mEq/L); the nurse would not question this medication. Riopan is a low-sodium antacid and is the antacid of choice for clients diagnosed with CHF. The nurse would not question this medication Comprehensive Examination. Pharmacology Success

12. The nurse is administering morning medications on a medical floor. Which medica- tion should the nurse administer first? 1. Regular insulin sliding scale to an elderly client diagnosed with Type 1 diabetes mellitus. 2. Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus. 3. Morphine, a narcotic analgesic, to a client diagnosed with Guillain-Barré syndrome. 4. Etanercept, a biologic response modifier, to a client diagnosed with rheumatoid arthritis.

✅1. Regular insulin sliding scale is adminis- tered prior to meals; therefore, this medication should be administered first. 2. This medication can be administered within the 30-minute acceptable time frame. 3. A pain medication is a priority, but it can be administered after the sliding scale. 4. Etanercept (Enbrel) can be administered within the 30-minute acceptable time frame

89. The nurse is preparing to administer warfarin (Coumadin), an anticoagulant. The client's current laboratory values are as follows: PT 48 PTT 40 Control 12.9 Control 36 INR 4.2 Which intervention should the nurse implement? 1. Question administering the medication. 2. Prepare to administer protamine sulfate. 3. Notify the health-care provider to increase the dose. 4. Administer the medication as ordered

✅1. The INR is outside of therapeutic range; therefore, the nurse should question administering this medication. Vitamin K is the antidote for Coumadin toxicity. Protamine sulfate is the antidote for heparin toxicity. There is no reason to notify the HCP to request an increase in the dose; the dose should be discontinued. The HCP should be notified of this abnormal lab data. 4. When the nurse is administering Coumadin, the International Normalized Ratio (INR) must be monitored to deter- mine therapeutic level, which is 2-3. Be- cause the INR is 4.2, the nurse should not administer this medication Comprehensive Examination. Pharmacology Success

62. The client diagnosed with bilateral conjunctivitis is prescribed antibiotic ophthalmic ointment. Which medication teaching should the nurse discuss with the client? Select all that apply. 1. Apply a thin line of ointment evenly along the inner edge of the lower lid margin. 2. Press the nasolacrimal duct after applying the antibiotic ointment. 3. Don nonsterile gloves prior to administering the medication. 4. Apply antibiotic ointment from the outer canthus to the inner canthus. 5. Instruct the client to sit with the head slightly tilted back or lie supine.

✅1. The client should instill eye ointment into the lower conjunctival sac, which is the inner edge of the lower lid margin. ✅2. This pressure will prevent systemic ab- sorption of the medication. 3. The client does not have to wear gloves when applying the ointment to his or her own eyes; the client should be instructed to wash hands prior to and after applying the ointment. The antibiotic ointment should be applied from the inner canthus to the outer can- thus, from the nose side of the eye to the outer area. ✅5. The client should be in this position when applying ophthalmic ointment or drops to better access the lower con- junctival sac.

90. The nurse is caring for a client diagnosed with pneumonia. Which data indicates the antibiotic therapy has been effective? 1. The white blood cell count is 7.2 (103) mg/dL. 2. The C&S shows gram-negative rods. 3. The client completed taking all the prescribed antibiotics. 4. The client complains of pleurisy.

✅1. The client's WBC count indicates a normal value, which would indicate the medication is effective. This culture indicates there is still infec- tion; therefore, the medication is not effective. This indicates medication compliance, not effectiveness of the medications. Pleurisy is noncardiac chest pain, which indicates that the medication is not effective. Comprehensive Examination. Pharmacology Success

59. The client has received chemotherapy 2 days a week every 3 weeks for the past 8 months. The client's current lab values are Hgb 10.3 and Hct 31, WBC 2000, neutrophils 50, and platelets 189,000. Which information should the nurse teach the client? Select all that apply. 1. Avoid individuals with colds or other infections. 2. Maintain nutritional status with supplements. 3. Do not allow the patient to eat raw fruit or have plants/flowers in the room. 4. Plan for periods of rest to prevent fatigue. 5. Use a soft-bristled toothbrush and electric razor.

✅1. The client's WBC is low and the ab- solute neutrophil count is 1100, which indicates the client is immunosup- pressed; therefore, the client should not be exposed to people with active infections. 2. This is good information to teach, but it is not based on the laboratory values. The client may develop mouth ulcers as a re- sult of chemotherapy administration and the nurse should discuss methods of maintaining nutrition for this reason, not the laboratory values. 3. The client's WBC is low and the absolute neutrophil count is 1100, which indicates the client is immuno- suppressed; therefore, the client should avoid contact with live plants or flowers (soil and standing water may have germs). 4. This is good information to teach, but it is not based on the laboratory values. Cancer and treatment-related fatigue are real and should be addressed; an Hgb and Hct of around 8 and 24 could cause fatigue, but at the current level this is not indicated. 5. A platelet count of less than 100,000 is the definition of thrombocytopenia; therefore, this client is not at risk for bleeding. Comprehensive Examination. Pharmacology Success

A client reveals that she is worried that she may be at risk for inherited cancer because her family is "full of cancer." She is most concerned about a risk for breast cancer because she has several relatives on her mother's side of the family who had breast cancer in their late 30s and early 40s. She says that one of her father's brothers died of breast cancer many years ago. She has several other family members who have had lung cancer and lymphoma. She reports that her primary health care provider (PHCP) says that male breast cancer "doesn't count" because it was on her father's side rather than in her mother's family and that the other cancer types in her family are from either environmental causes or "just a coincidence." The client also tells you that when she asked her primary health care provider about the possibility of testing, that he told her she worries too much about everything and that it is unlikely that testing would be beneficial for her. 1.Are there any "red flags" of relevant information in this client's family history that raise a concern about any form of hereditary cancer? If so, what are they? 2.How should the nurse respond to the client's report that her PHCP says she worries too much and has not considered her request for genetic/genomic testing for hereditary breast cancer? 3.What additional information should the nurse obtain from this client? 4.What is the best course of action to ensure that this client receives an appropriate level of genetic counseling?

✅1. The major red flags are associated with breast cancer risk. She relates multiple family members who were diagnosed with premenopausal breast cancer. The paternal uncle with breast cancer is a big red flag because breast cancer in men is rare and mostly associated with specific gene mutations. ✅2.It is possible that this client has a history with the PHCP of many health care worries. Sometimes such a history reduces the sensitivity of the PHCP to the possibility that a real problem may exist. The nurse could suggest to the client that perhaps the information she reported to the PHCP was not heard correctly or may have been delivered in an unorganized way. Offer to help the client organize her information. Also explain that a PHCP is not a genetics specialist and may not be fully aware of the significance of the information, nor should he or she be expected to be. ✅3. The first step in this situation would be to perform a detailed family history in pedigree format for a minimum of 3 generations (another generation or two would be even more helpful). In addition to the general maternal and paternal information for family history, the pedigree should include all data about who in the family actually developed cancers, the age they were diagnosed, how they were treated, and whether or not they died of the disease. Also ascertain the exact relationship of these individuals to the client, especially determining whether they were "blood relatives," and close the relationship is to the client. Ask the client about the specific ethnicity of the relatives in each generation of the family. ✅4. After obtaining a complete family history and generating a detailed pedigree, the nurse should analyze the pedigree looking for indications of a pattern of inheritance for the cancers. Although environmental cancers may be present with some hereditary forms of cancer, if the overall cancer rate appears higher-than-average, genetic factors could also be influential. If a pattern emerges or if the overall cancer incidence is high, the nurse should first show these findings to a lower level genetics professional to ensure that the nurse is correctly analyzing the information. Then the nurse could approach the PHCP and explain why he or she (the nurse) is concerned. When the approach to the PHCP is organized and clear, the provider is more likely to pay closer attention. Pedigrees provide a visual presentation of the degree of family involvement for a health problem and this can alert the PHCP to the need for genetic counseling. If the nurse also suggests that a referral to a certified genetics counselor does not change the PHCP's relationship with the client but can relieve his or her sole responsibility in this matter. Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

99. The client diagnosed with diabetes insipidus (DI) is receiving desmopressin (DDAVP), a pituitary hormone, intranasally. Which assessment data warrants the client notifying the health-care provider? 1. The client complains of being thirsty all the time. 2. The client is able to sleep through the night. 3. The client has lost 1 pound in the past 24 hours. 4. The client has to urinate at least five times daily.

✅1. The major symptom with DI is polyuria resulting in polydipsia (extreme thirst); therefore, the client being thirsty indi- cates the medication is not effective and would warrant notifying the health-care provider. If the client is able to sleep throughout the night, this indicates the client is not up urinating as a result of polyuria; therefore, the medication is effective. A weight loss of 1 pound would not war- rant notifying the health-care provider. The client only urinating five times a day indicates the medication is effective; therefore, the client would not have to notify the HCP Comprehensive Examination. Pharmacology Success

Teamwork and Collaboration; Safety A 76 year old female was admitted from acute care to the inpatient rehabilitation facility (IRF) following a fall at home that resulted in hip fracture, requiring a total hip replacement. In addition, the client broke her left wrist and index finger in the fall. The client has a functional independence measure of 3. History includes hypertension, poorly controlled Type II diabetes mellitus, hypercholesteremia and anxiety. Prior to the fall and subsequent hip surgery, the client lived at home alone with one son that lives across the country. Physical therapy consulted with in the acute care setting and the client has transferred to the chair but is resistant to ambulation due to pain and anxiety and does not want to turn in the bed regularly. Occupational therapy has started working on fine motor rehab of the client's left hand and fingers. 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to help you determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: think about priority collaborative problems that support and contradict the information presented in this situation.) 3. What possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided, are irrelevant, or are potentially harmful? (Hint: Determine the desired outcomes first to help you decide which actions are appropriate and those that should be avoided.)

✅1. The most relevant assessment information that the nurse will identify is the limited mobility, recent total hip replacement, and history of poorly controlled Type II diabetes mellitus. The fact that the client previously lived at home alone with minimal support is also relevant. ✅2. The acute hip replacement, limited mobility in acute care, and the history of poorly controlled diabetes mellitus create a significant risk for continued mobility concerns and pressure injury. The fact that the client lives at home alone and has minimal support will affect the long-term rehabilitation goals. ✅3. It would be reasonable to assume that pain and her history of anxiety may be affecting her rehabilitation progress. Therefore, addressing pain appropriately will most likely promote mobility. As the client begins to move more the risk of the tissue injury will decrease. Controlling the client's blood sugar is important to promote healing of tissues and to prevent infection. It is important to note that the nurse is not making a medical diagnosis. Rather, the nurse is using critical thinking proactively to anticipate cause and effect, which will lead to effective clinical judgement. ✅4. Moving forward with an interprofessional plan of rehabilitation to promote mobility of the hip and the fractured hand and fingers will move the client toward the desired outcome of returning to independent function. Safety precautions are required to avoid falling and the use of safe patient handling and mobility (SPHM) is very important for the client with low functional ability who is post hip replacement. Moving the client inappropriately could be harmful. Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

A 27-year-old, female client with spina bifida with a history of pressure injuries is sent to the hospital by the home health RN who visits once every two weeks. The client has a temperature of 101.9F and multiple stage 2 pressure injuries on her buttocks. The client is allergic to penicillin and has seasonal allergies to mold. During assessment, the client states, "I don't have a life and I can't work so I don't have any money." The client appears disheveled and is noted to have body odor. 1. What assessment information in this client situation is the most important and of immediate concern for the nurse? (Hint: Identify the relevant information first to help you determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided, are irrelevant, or are potentially harmful? (Hint: Determine the desired outcomes first to help decide which actions are appropriate and those that should be avoided.) 5. Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) . 6. What client assessment would indicate that actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

✅1. The most relevant information that the nurse will identify is the decrease in mobility, fever and the presence of pressure injuries on the client's buttocks. The client's allergy to penicillin is also relevant to care. It is important to listen to the psychosocial needs presented; however, the most relevant information will lead you to the most important needs that you will address first. Seasonal allergies are irrelevant to the priority of care at this time. ✅2. The client's history of spina bifida affects mobility and can create risks for tissue injury impairment which connects directly to the identified relevant information. ✅3. The client most likely has a temperature of 101.9F as a result of infection from the stage 2 pressure injuries that were most likely caused by limited mobility associated with spina bifida. Continued skin breakdown could increase the risk factors for this client. Infections that are not treated properly can lead to sepsis which can become life threatening. It is important to note that as a nurse, you are not making a medical diagnosis. You are using critical thinking proactively to anticipate cause and effect, which will lead to effective clinical judgement. ✅4. The client will most likely need an antibiotic to treat infection, an antipyretic to decrease the fever and wound care to treat the existing alterations in tissue integrity. Understanding the allergy to penicillin is of critical importance as this client will most likely be prescribed an antibiotic to treat the infection. Administering penicillin would be harmful to the client. While the pressing issue is to treat the infection and provide wound care, the client will also need interprofessional consultation to address psychosocial needs. Nursing assessment reveals that the client needs more support at home to prevent recurrence in skin breakdown and promote mobility. Failure to address these needs could be harmful to the client. ✅5. Client assessment is the priority action. Assessment includes gaining more information about the status of tissue integrity and may include actions such as wound cultures and laboratory testing (such as WBC count) to confirm infection and determine the appropriate course of antibiotic therapy. Assessment data indicates that the client needs more in-home assistance with activities of daily living. Interprofessional collaboration with the healthcare provider, wound care nurse, social worker, and registered dietitian nutritionist is also warranted. Client education regarding skin care and the impact of decreased mobility is also important and will occur after the priority of care has been addressed ✅6. Signs of effective actions include a decrease in temperature, improvement in WBC count, and improvement in tissue integrity. If the infection progresses, the client may demonstrate signs of sepsis which could include a rise in temperature, changes in level of consciousness, increase in heart rate, or decrease in urine production. With treatment of the infection and effective wound care, the nurse would anticipate improvement in the overall tissue integrity. The status of the client's spina bifida will remain unchanged and is only related as the cause of the immobility. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

38. The nurse is preparing to administer medications to the following clients. Which client should the nurse question administering the medication? 1. Lactulose (Cephulac), a laxative, to a client who has an ammonia level of 10 μg/dL. 2. Furosemide (Lasix), a loop diuretic, to a client who has a potassium level of 3.7 mEq/L. 3. Spironolactone (Aldactone), a potassium-sparing diuretic, to a client with a potassium level of 3.5 mEq/L. 4. Vasopressin (Pitressin) to a client with a serum sodium level of 137 mEq/L.

✅1. The normal plasma ammonia level is 15-45 μg/dL (varies with method); this is below the normal level. The client with end-stage liver failure would be receiving this medication, and the client does not need to receive a laxa- tive that will cause diarrhea. The normal serum potassium level is 3.5-5.5 mEq/L; therefore, the nurse should administer this medication because the potassium level is within normal limits. The normal serum potassium level is 3.5-5.5 mEq/L; therefore, the nurse should not question administering this medication because the potassium level is within normal limits. Hyponatremia (normal sodium 135- 145 mEq/L) may occur when the client is taking vasopressin therapy. This sodium level is within normal limits; therefore, the nurse would not question administering this medication. Comprehensive Examination. Pharmacology Success

74. The nurse is administering heparin via the subcutaneous route. Which interventions should the nurse implement? Select all that apply. 1. Prepare the medication using a 25-gauge, 1/2-inch needle. 2. After injecting the medication do not aspirate. 3. Check the client's PTT prior to administering the medication. 4. After removing the needle, massage the area gently. 5. Administer the medication in the client's "love handles."

✅1. The nurse should prepare the medica- tion using a 25-gauge, 1/2- to 5/8-inch needle. ✅2. The nurse should not aspirate for blood when administering heparin because this can damage surrounding tissue and cause bruising. 3. The client's PTT is not monitored for subcutaneous administration of heparin because the heparin must be administered intravenously to increase the PTT level. 4. The nurse should not massage after inject- ing heparin because this may cause bruis- ing or bleeding. 5. Heparin is administered in the lower ab- dominal area at least 2 inches from the umbilicus. Lovenox is administered in the "love handles," located anterolateral to the upper abdomen

92. The client diagnosed with inflammatory bowel disease is prescribed mesalamine (Asacol) suppository, an aspirin product. Which statement indicates the client needs more medication teaching? 1. "I should retain the suppository for at least 15 minutes." 2. "The suppository may stain my underwear or clothing." 3. "I should store my medication in my medication cabinet." 4. "I should have an empty rectum when applying the suppository."

✅1. The suppository should be retained for 1-3 hours if possible to get the maxi- mum benefit of the medication. This statement indicates the client does not understand the medication teaching. The client should use caution when using the suppository because it may stain cloth- ing, flooring, painted surfaces, vinyl, enamel, marble, granite, and other sur- faces. This statement indicates the client understands the teaching. The medication should be stored at room temperature away from moisture and heat. This indicates the client understands the teaching. The client should empty the bowel just before inserting the rectal suppository. This statement indicates the client under- stands the teaching Comprehensive Examination. Pharmacology Success

33. The client's arterial blood gas results are pH 7.35, PaO2 75, PCO2 35, and HCO3 24. Which intervention is most appropriate for this client? 1. Administer oxygen 10 L/min via nasal cannula. 2. Administer an antianxiety medication. 3. Administer 1 amp of sodium bicarbonate IVP. 4. Administer 30 mL of an antacid.

✅1. This client has normal ABGs, but the oxygen level is below normal (80-100); therefore, the nurse should administer oxygen. The client has normal ABGs; therefore, an antianxiety medication does not need to be administered. The client needs oxygen. Sodium bicarbonate is the drug of choice for metabolic acidosis and this client has normal ABGs except for hypoxia. The client has normal ABGs with hypoxia. Comprehensive Examination. Pharmacology Success

64. The client in hypovolemic shock is receiving normal saline by rapid intravenous infu- sion. Which assessment data warrants immediate intervention by the nurse? 1. The client's blood pressure is 89/48. 2. The client's pulse oximeter reading is 95%. 3. The client's lung sounds are clear bilaterally. 4. The client's urine output is 120 mL in 3 hours.

✅1. This is a low blood pressure reading for a client in hypovolemic shock. A B/P less than 90/60 warrants interven- tion by the nurse and indicates the fluid resuscitation is not effective. A pulse oximeter reading of greater than 93% indicates the arterial oxygen level is between 80 and 100, which is normal. The client's lungs are clear, which indi- cates the client is not in fluid-volume overload; therefore, this does not warrant immediate intervention. If the client has at least 30 mL of urine output an hour, then the kidneys are being perfused adequately. This indicates the client is urinating 40 mL an hour.

5. Which statement best describes the scientific rationale for prescribing the thiazo- lidinedione (pioglitazone) (Actos)? 1. This medication increases glucose uptake in the skeletal muscles and adipose tissue. 2. This medication allows the carbohydrates to pass slowly through the large intestine. 3. This medication will decrease the hepatic production of glucose from stored glycogen. 4. This medication stimulates the beta cells to release more insulin into the bloodstream.

✅1. This is scientific rationale for adminis- tering thiazolidinediones, pioglitazone (Actos), or rosiglitazone (Avandia). 2. This is the scientific rationale for administer- ing an alpha-glucosidase inhibitor, acarbose (Precose), or miglitol (Glyset). 3.This is the scientific rationale for administer- ing metformin (Glucophage). It diminishes the increase in serum glucose following a meal and blunts the degree of postprandial hyperglycemia. 4.This is the scientific rationale for adminis- tering meglitinides, repaglinide (Prandin), sulfonylureas, or nateglinide (Starlix). Comprehensive Examination. Pharmacology Success

18. Which statement best describes the scientific rationale for administering a miotic ophthalmic medication to a client diagnosed with glaucoma? 1. It constricts the pupil, which causes the pupil to dilate in low light. 2. It dilates the pupil to reduce the production of aqueous humor. 3. It decreases production of aqueous humor but does not affect the eye. 4. It is used as adjunctive therapy primarily to reduce intraocular pressure.

✅1. This is the scientific rationale for mi- otic medications, which constrict the pupil and block sympathetic nervous system input, causing the pupil to dilate in low light and contract the ciliary muscle. 2. This is the scientific rationale for mydriatic medications, which dilate the pupil, reduce the production of aqueous humor, and increase the absorption effectiveness, re- ducing intraocular pressure in open-angle glaucoma. 3. This is the scientific rationale for beta- adrenergic blockers, which reduce intraoc- ular pressure but do not affect pupil size and lens accommodation 4. This is the scientific rationale for carbonic anhydrase inhibitors, which reduce in- traocular pressure.

32. The client diagnosed with chronic obstructive pulmonary disease is prescribed methylprednisolone (Solu-Medrol), a glucocorticoid, IVP. Which laboratory data warrants intervention by the nurse? Select all that apply. 1. The white blood cell (WBC) count is 15,000. 2. The hemoglobin and hematocrit levels are 13 g/dL and 39%. 3. The blood glucose level is 238 mg/dL. 4. The creatinine level is 1.2 mg/dL. 5. The potassium level is 3.9 mEq/L.

✅1. White blood cells are monitored to detect the presence of an infection, and an elevated WBC is a sign of infection that would warrant intervention. Steroids mask infection. The hemoglobin and hematocrit are mon- itored to detect blood loss, not for steroid therapy. Steroid therapy interferes with glucose metabolism and increases insulin resistance. The blood glucose levels should be moni- tored to determine if an intervention is needed and a glucose level of 238 would warrant intervention. The creatinine is monitored to determine renal status. The adrenal glands produce cortisol. The client's potassium level is within nor- mal limits; therefore, this does not warrant intervention Comprehensive Examination. Pharmacology Success

14. Which interventions should the nurse implement when administering the biologic response modifier filgrastim (Neupogen) subcutaneously? Select all that apply. 1. Do not shake the vial prior to preparing the injection. 2. Apply a warm washcloth after administering the medication. 3. Discard any unused portion of the vial after withdrawing the correct dose. 4. Keep the medication vials in the refrigerator until preparing to administer. 5. Instruct the client to take acetaminophen prior to and 24 hours after injection.

✅1.Do not shake the vial because shaking may denature the glycoprotein, rendering it biologically inactive. 2.The nurse should apply ice to numb the injection site, not a warm washcloth. ✅3. The nurse should only use the vial for one dose. The nurse should not reen- ter the vial and should discard any un- used portion because the vial contains no preservatives. ✅4. The medication should be stored in the refrigerator and should be warmed to room temperature prior to adminis- tering the medication. ✅5. The medication can cause bone pain; therefore, the nurse should encourage the client to take Tylenol before and after the injection to decrease pain. Comprehensive Examination. Pharmacology Success

A 60-year old client with a history of opioid misuse fell a week ago, and did not seek care until two days ago when a grandchild found him lying in the kitchen of his residence. He was then brought and admitted to the hospital. Having just had hip replacement surgery, he is now readmitted to the medical-surgical unit from the PACU. He is responsive when asked his name yet is mildly confused about where he is. He is pulling at his oxygen cannula but does allow it to be replaced into his nostrils. Initial vital signs upon return to the medical-surgical unit included BP 140/90, pulse 100, respirations 22. Vital signs taken 15 minutes later show BP 142/92, pulse 100, respirations 22. He says he hurts "really badly" and wants to know when he will receive pain medication. 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.) 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.) 5. Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. What client assessment would indicate that the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

✅1.It is relevant to note that the client has a history of opioid misuse, and that his behaviors (pulling at the cannula and questioning when he will receive pain medication) are indicative of pain. His vital signs, including an elevated blood pressure, pulse on the high end of normal, and increased respirations, have not changed dramatically between the first and second assessment, which indicates that the problem is still present. ✅2. Pain, or delirium, are two client conditions that could be consistent with the most relevant information. It is important to note, however, that the client is able to respond to his name, and to form a coherent thought about pain medication. ✅3. The client is most likely experiencing pain. Having a history of opioid misuse, he may not respond to the normal amount of pain medication administered after surgery; he may need a higher dose. ✅4. It is most likely that administration of pain medication in a dose that truly addressed the client's pain will achieve the desired outcome. Ignoring the client's concern could be potentially harmful, as pain will continue to increase, and the client's restlessness will rise in proportion. This can affect the healing process. ✅5. An assessment should be completed. Vital signs should be compared against the client's presurgical baseline. Attention should be given to whether the patient has a fever (which may indicate delirium). In the absence of other findings, the nurse should determine when the next pain medication is due, and what dose has been prescribed. If needed, the nurse should then collaborate with the surgeon to determine if the appropriate dose has been prescribed, given the patient's presentation and history. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

86. The nurse is discharging a client diagnosed with chronic obstructive pulmonary dis- ease (COPD). Which discharge instructions should the nurse provide regarding the client's prednisone, a glucocorticoid? Select all that apply. 1. Explain the prednisone must be tapered when discontinuing. 2. Take the prednisone with food to prevent gastrointestinal upset. 3. Stop taking the prednisone if a noticeable weight gain occurs. 4. Keep the prednisone in a dark-colored bottle at all times. 5. The medication will increase the risk of developing an infection.

✅1.Steroids (glucocorticoids) cannot be abruptly discontinued because the ad- renal glands stop producing cortisol (a steroid) when the client is taking them exogenously and the client could experience a hypotensive crisis. ✅2. Prednisone can produce gastric dis- tress; it is given with food to minimize the gastric discomfort. Weight gain is a side effect of steroid therapy; the client should not stop taking the medication. This medication must be tapered off if the client is able to discon- tinue the medication at all 4. Prednisone is not affected by light so it does not have to be kept in a dark-colored bottle. Sublingual nitroglycerin needs to be kept in a dark-colored bottle. ✅5.Prednisone, a steroid, suppresses the immune system response of the body, increasing the risk of developing an infection Comprehensive Examination. Pharmacology Success

11. The elderly client calls the clinic and is complaining of being constipated and having abdominal discomfort. Which interventions should the nurse implement? Select all that apply. 1. Instruct the client to take an OTC laxative as recommended on the label. 2. Recommend the client drink clear liquids only, such as tea or broth. 3. Determine when the client last had a bowel movement. 4. Tell the client to go to the emergency department as soon as possible. 5. Ask the client what other medications are currently being taken.

✅1.The nurse can recommend the client take over-the-counter (OTC) medica- tion to help relieve the constipation. 2. The client should be encouraged to eat high-fiber foods and increase fluid intake, preferably water. ✅3. The nurse should determine when the last bowel movement was so that ap- propriate action can be taken to resolve the constipation. 4. The client does not need to go to the emergency department because the consti- pation should resolve with medication, but the client may need to be seen in the clinic if there is still no bowel movement within several days. ✅5. The nurse should determine what other medications the client is taking because constipation can be a side effect of many prescribed and OTC medications.

44. The nurse observes the unlicensed assistive personnel (UAP) performing nursing tasks. Which action by the UAP requires immediate intervention? 1. The UAP increases the rate of the saline irrigation for a client who had a transurethral resection of the prostate. 2. The UAP tells the nurse that a client who is on strict bed rest has green, funny- looking urine in the bedpan. 3. The UAP encourages the client to drink a glass of water after the nurse adminis- tered the oral antibiotic. 4. The UAP assists the client diagnosed with a urinary tract infection to the bedside commode every 2 hours

✅1.The saline irrigation is being instilled into the bladder and requires nursing judgment; therefore, this nursing task requires immediate intervention. The UAP reporting abnormal data is ap- propriate. A green-blue color indicates the client is taking bethanechol (Urecholine), a urinary stimulant used for clients with a neurogenic bladder. This is an expected color. The client should be encouraged to drink fluids. The nurse would not intervene to stop this action. This action encourages bowel and urine continence and is part of a falls prevention protocol. The nurse would not intervene to stop this action Comprehensive Examination. Pharmacology Success

77. The nurse is preparing to administer the following anticonvulsant medications. Which medication should the nurse question administering? 1. Carbamazepine (Tegretol) to the client who has a Tegretol serum level of 22 μg/mL. 2. Clonazepam (Klonopin) to the client who has a Klonopin serum level of 60 ng/mL. 3. Phenytoin (Dilantin) to the client who has a Dilantin serum level of 19 μg/mL. 4. Ethosuximide (Zarontin) to the client who has a Zarontin serum level of 45 μg/mL.

✅1.The therapeutic serum level of Tegre- tol is 5-12 μg/mL; therefore, the nurse should question administering this medication. The therapeutic serum level of Klonopin is 20-80 ng/mL; therefore, the nurse should administer this medication. The therapeutic serum level of Dilantin is 10-20 μg/mL; therefore, the nurse should administer this medication. The therapeutic serum level of Zarontin is 40-100 μg/mL; therefore, the nurse should administer this medication Comprehensive Examination. Pharmacology Success

A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate? 10 to15 lb 15 to 20 lb 25 to 35 lb 35 to 45 lb

✅25 to 35 lb To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. The recommended weight gain for women with an average BMI is 11.5 to 16 kg, or roughly 25 to 35 lb. This amount is sufficient to ensure that the fetus is adequately nourished. 10 to15 lb To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. A weight gain of 10 to 15 lb is below the recommended weight gain for a client who has a normal BMI and is pregnant with a single fetus. Too little or too much weight gain could mean potential health problems. 15 to 20 lb To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. A weight gain of 15 to 20 lb is below the recommended weight gain for a client who has a normal BMI and is pregnant with a single fetus. 35 to 45 lb To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. The recommended weight gain for women with an average BMI is 11.5 to 16 kg, or roughly 25 to 35 lb. This amount is sufficient to ensure that the fetus is adequately nourished. A weight gain of 35 to 45 lb is above the recommended weight gain a client who has a normal BMI and is pregnant with a single fetus. NurseLogic Knowledge and Clinical Judgment Advanced

The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? 3:30 p.m. 4:30 p.m. 4:00 p.m. 7:00 p.m.

✅4:30 p.m. The nurse will change the dressing at 4:30 p.m. About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a client. At 4:30 p.m., the opioid has had time to take effect and provide relief for the client. It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 p.m.), because the pain medication will be at its lowest concentrations in the client's system. At 4:00 p.m., the analgesic has not had time to enter the client's system, so it is too soon to perform the dressing change. If the client received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 p.m. to facilitate a dressing change with minimal discomfort. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

52. The client has second- and third-degree burns to 40% of the body. The HCP writes an order for 8000 mL of fluid to be infused over the next 24 hours. The order reads that half of the total amount should be administered in the first 8 hours with the other half being infused over the remaining 16 hours. At what rate would the nurse set the intravenous pump for the first 8 hours?

✅500 mL/hour. The nurse should divide 8000 mL by 2, which equals 4000 mL. The 4000 must be divided by 8, which equals 500 mL/hour. There are formulas that are used to determine the client's fluid-volume resuscitation. The formulas specify that the total amount of fluid must be infused in 24 hours, 50% in the first 8 hours followed by the other 50% over the other 16 hours. This is a large amount of fluid, but it is not uncommon in clients with full-thickness burns over greater than 20% total body sur- face area burned Comprehensive Examination. Pharmacology Success

13 of 18 The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? A 62 year old with lung cancer who has cool, clammy, dusky skin, and blood pressure of 64/20 mm Hg. A 26 year old with metastatic breast cancer who is experiencing pain rated at 8 (0-10 scale) and anxiety. A 70 year old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations. A 30 year old with AIDS-associated dementia and agitation who is asking for assistance with calling family members.

✅A 26 year old with metastatic breast cancer who is experiencing pain rated at 8 (0-10 scale) and anxiety. Management of pain is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action. The client with AIDS needs rapid assistance, but is the second priority for the nurse in this scenario. The client with lung cancer and the client with colon cancer are exhibiting normal signs and symptoms associated with dying. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

Which client does the nurse identify at greatest risk for slow wound healing? A 47-year-old man with obesity and diabetes A 58-year-old woman who smokes 2 packs of cigarettes daily A 78-year-old man with controlled hypertension A 21-year-old woman with an STI

✅A 47-year-old man with obesity and diabetes Obesity and diabetes significantly place a client at greatest risk for slow wound healing. The other clients may encounter slower wound healing, yet they are not at the highest risk like the client with obesity and diabetes. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Question 8 of 13 Which nursing action demonstrates use of the principle of justice? A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer. An 82-year-old client is provided access to the hospital Patient Advocate for processing of a complaint. A 32-year-old client is prevented from falling during the initial postoperative period following her hysterectomy. The parents of a 13 year old are included in discussions about the course of their teen's treatment and care

✅A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer. The principle of justice refers to equality—all clients should be treated equally and fairly, as demonstrated by the respect shown to the client with dementia. The 32-year-old's fall prevention relates to providing a safe care environment, which is an important nursing principle but is not categorized as justice. Providing the 82-year-old client access to the hospital Patient Advocate is an example of the principle of self-determination through facilitation of the client's autonomy. Including the parents of the 13 year old in the discussion about care represents an example of dependent care, not the principle of justice. Teens may not legally be empowered as the final decision makers in their own care. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

The nurse has been effectively using digital stimulation in older adult clients with constipation problems. For which client is this practice unsafe? A 70 year old with recently diagnosed atrial fibrillation A 68 year old with a long history of multiple sclerosis (MS) A 74 year old who is 4 months poststroke An 84 year old with progressive dementia and confusion

✅A 70 year old with recently diagnosed atrial fibrillation The practice is unsafe for a 70 year old with recently diagnosed atrial fibrillation. Digital stimulation is contraindicated in clients with cardiac disease because of the risk of initiating a vagal nerve response. Instead, another method of treatment for constipation should be used, such as diet, fluids, or laxatives. The client with MS, the client who is poststroke, and the client with dementia and confusion are safe risks. These clients would not have a higher risk of negative effects from digital stimulation than the average person without cardiac issues Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

Question 3 of 15 The nurse is providing care for a client who recently had a brain attack. Which member of the interprofessional health care team does the nurse identify that can help the client improve skills to perform ADLs? A. Assistive personnel B. Physical therapist C. Licensed social worker D. Occupational therapist

✅A client receives an annual physical where the cost has been predetermined as $80. Managed care is a type of organized delivery of care where costs have been determined by the managed care company and health care providers. Therefore, the client whose fixed cost for a physical at $80 is being treated via managed care. Being admitted to a hospital is part of inpatient care. Seeing a designated family physician is part of primary health care. Obtaining vaccinations at a local community health center is part of community health care. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions? A client who has rubella A client who has measles A client who has hepatitis A A client who has Rocky Mountain spotted fever

✅A client who has rubella To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Rubella is transmitted through the nasopharyngeal secretions of the infected person, and is also found in blood, stool, and urine. Because droplets associated with the illness are larger than 5 mcg, the Centers for Disease Control and Prevention recommends placing clients who are diagnosed with rubella on droplet precautions. Droplet precautions include placing the client either in a private room or with other clients who have the same disease, as well as using of a mask or respirator when providing care. This client should be placed on droplet precautions. A client who has measles To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Measles is transmitted through respiratory secretions of the infected person and is also found in blood and urine. Because droplets associated with this illness are smaller than 5 mcg, the Centers for Disease Control and Prevention recommends placing clients who are diagnosed with measles on airborne precautions. Airborne precautions include a private room with HEPA filtration that creates negative-pressure airflow. This client should be placed on airborne, instead of droplet, precautions. A client who has hepatitis A To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Hepatitis A is transmitted through the fecal-oral route most often by eating contaminated foods and does not require the client be placed on droplet precautions. The Centers for Disease Control and Prevention recommends the use of standard precautions when caring for a client who has hepatitis A. Standard precautions include following specific criteria to protect the client and the nurse when coming in contact with blood, body fluids, open skin lesions, or the mucous membranes of all clients. This client does not need to be placed on droplet precautions. A client who has Rocky Mountain spotted fever To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Rocky Mountain spotted fever is transmitted through the bite of an infected tick and is only transmissible person-to-person through a blood transfusion. The Centers for Disease Control and Prevention recommends the use of standard precautions when caring for a client who has Rocky Mountain spotted fever. Standard precautions include following specific criteria to protect the client and the nurse when coming in contact with blood, body fluids, open skin lesions, or the mucous membranes of all clients. This client does not need to be placed on droplet precautions. NurseLogic Knowledge and Clinical Judgment Advanced

A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform an electronic blood pressure measurement? A client who is recovering from a cardiac catheterization A client who is in stage 4 of Parkinson's disease A client who has anorexia and hypotension A client who has a temperature of 39.1° C (102.4° F) and is shivering

✅A client who is recovering from a cardiac catheterization In this item, you need nursing knowledge of how blood pressure measurement can be impacted by the stages of Parkinson's disease, hypotension, shivering, and cardiac catheterization. Additionally, specific knowledge of electronic blood pressure measurement is needed to select the correct option. This item requires critical thinking because you have to analyze the four clients and determine for whom an electronic blood pressure is appropriate. Electronic blood pressure measurement is attained through a sensor that detects vibrations caused by blood rushing through the artery, is appropriate for use when the blood pressure must be monitored frequently, and should not be taken on clients with conditions that can result in an inaccurate reading. A client who is recovering from a cardiac catheterization requires frequent blood pressure measurements. It is appropriate to perform an electronic blood pressure measurement on this client. NurseLogic Knowledge and Clinical Judgment Advanced

18 of 18 The nurse is teaching a class on advance directives. What will the nurse include? (Select all that apply.) Select all that apply. A durable power of attorney for health care is the same as a durable power of attorney for one's health care. A living will identifies health care wishes regarding end of life treatment. A health care proxy can only make decisions once a person no longer has their own ability to make decisions. In order to make a health care decision, a person much be totally oriented. A living will contains funeral directives as well as last wishes for family. Advance directive are the same from state to state.

✅A living will identifies health care wishes regarding end of life treatment. ✅A health care proxy can only make decisions once a person no longer has their own ability to make decisions. Advance directive vary from state to state. While all have similarities, each state is unique. A durable power of attorney for health care is not the same as the durable power of attorney for finances. This can be the same person—but must be defined specifically for both roles. A living will identifies would an individual would (or would not) want when he or she is near death. A living will contains information specific to artificial ventilation, and nutrition or hydration as well as resuscitation directives. It does not contain funeral directives or last wishes for family. In order to make a health care decisions, a person does not need to be totally oriented. However, he or she must be able to receive information and then evaluate, deliberate, and manipulate the information as well as communicate a treatment preference. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the client's code status to do-not-resuscitate (DNR)? A written prescription from the provider Signed documentation from the client Family support of the decision Admission to hospice for palliative care

✅A written prescription from the provider In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. A DNR is typically instituted at the request of a client or family member and should be a written order instead of a verbal prescription. Until a DNR prescription exists, every attempt to revive the client should be made in the event of respiratory or cardiac arrest. A written prescription from the provider is necessary to legally change the client's code status to a DNR. Signed documentation from the client In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. The client, or the client's health care proxy if the client is not competent, should be notified by the provider before writing a prescription for a DNR. While the client and family should be in agreement, signed documentation is not a legal requirement to change the client's code status to a DNR. Family support of the decision In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. Because the client is competent to make decisions, his requests should be given the highest priority; therefore, family support of the decision is not needed. If the client was not competent, the client's healthcare proxy or advance directives should guide the care of the client. Admission to hospice for palliative care MY ANSWER In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. A DNR prescription signifies that the treatment goal is a comfortable, dignified death. While palliative care is appropriate for the client, admission to hospice is not needed to legally change the client's code status to a DNR. NurseLogic Knowledge and Clinical Judgment Advanced

A client with opioid depression has received naloxone. Vitals signs are currently recorded as BP 110/70, P 70, R 16, and T 98.9° F. Which additional treatment does the nurse anticipate will be needed? A. Supplemental pain medication B. Activation of the Rapid Response Team C. External pacing to regular heartbeat D. Restraints due to naloxone causing agitation

✅A. Supplemental pain medication Supplemental pain medication will be anticipated, as reversal of the opioid via naloxone reduces the analgesic effect also. The vital signs do not warrant activation of the Rapid Response Team, external pacing, nor restraints. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Question 11 of 15 Which factor does the nurse identify that influences client outcomes? (Select all that apply.) Select all that apply. A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies D. What the individual client believes about health? E. Technology that is available in the local community health center F. The application of systems thinking to care of clients

✅ANS ABCEF A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies E. Technology that is available in the local community health center F. The application of systems thinking to care of clients Knowledge and experience of the health care professional influence client outcomes. Other factors that directly influence client outcomes include: · Behavioral and social determinants of health: What "health" means to each client within the context of his or her culture · New approaches to population health management: evidence-based care that is delivered to individuals, communities, and populations · Policy and health care reform: legislation at all levels of government, which influence health care as a right rather than a privilege · Available and emerging technologies: the use of which assesses for health risks and influences treatment plans · Interprofessional practice: the collaboration of all health care team members who are focused on patient-centered care · Shift towards systems thinking: the recognition that health maintenance, health care activities, and health care interventions do not occur in isolation, and that lessons can be learned from individual care that pertains to a larger group of patients (and vice versa) Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

A nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. Which of the following findings requires further intervention? Vesicular rash Respiratory rate 54/min Abdominal distension Heart rate142/min

✅Abdominal distension In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. Abdominal distension that is present at birth indicates a tumor or an abdominal wall defect, such as a ruptured viscus. This finding should be reported to the provider immediately and evaluated further. Vesicular rash In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. A vesicular rash is indicative of erythema toxicum, which is a transient rash caused by an inflammatory response in neonates born at 36 weeks of gestation or more. It is thought that the rash is caused by the presence of eosinophils, which assist in reducing inflammation, in small vesicles that appear suddenly on the body during the first 3 weeks of life. Treatment of the rash is not required, as it has no clinical significance. Respiratory rate 54/min In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. Shallow, irregular respirations of 54/min is within the expected reference range for a newborn. This finding does not require further intervention. Heart rate142/min In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. A heart rate of 142/min is within the expected reference range for a newborn. This finding does not require further intervention. NurseLogic Knowledge and Clinical Judgment Advanced

The nurse is caring for a client who reports pain. As an advocate for the client, what will the nurse do first for this client? Assess the level of pain. Administer pain medication. Accept the client's report of pain. Call the health care provider for a medication order.

✅Accept the client's report of pain. The nurse's primary role in pain management is to advocate for the client by accepting reports of pain, as such, this is the nurse's first action. This has become the clinical definition of pain worldwide and reflects an understanding that the client is the authority and the only one who can describe the pain experience. In other words, self-report is always the most reliable indication of pain. Administering pain medication, assessing the pain level, and calling the provider are responses to the first response which is accepting that the client is in pain. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

Question 9 of 13 When developing a standardized plan of care for clients with a diagnosis of pneumonia, how does the nurse find the best information about providing optimal nursing care? Survey experienced RNs about which nursing actions are effective when caring for clients with pneumonia. Research the most recent articles in nursing magazines that discuss care for clients with pneumonia. Review the chart to determine what primary health care provider's prescriptions are frequently written for clients with pneumonia. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia.

✅Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia. The best evidence-based nursing practice will be developed by using information from randomized controlled studies testing the impact of various nursing interventions on outcomes for clients with pneumonia. This type of data collection is the most scientifically based approach listed here. Articles in nursing magazines are likely to be researcher biased. They are also unlikely to be controlled. Chart review serves as a limited source of data and cannot be generalized for a standard. Also, regional practices may tend to skew the data. Data from nurses, although valuable, are likely to be biased; data collection would not be well controlled. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

A postoperative client reports, "I have pain from a mild headache." Which PRN medication will the nurse administer? Oxycodone Hydromorphone Midazolam Acetaminophen

✅Acetaminophen The nurse will administer acetaminophen as prescribed. Nonopioid analgesics such as acetaminophen are the first line of therapy for mild to moderate pain. Hydromorphone is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Midazolam is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Oxycodone is an opioid and is not needed for a mild headache. Question Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What is the priority nursing action? Perform a cognitive assessment on the client. Call the care provider for a change in the medication order. Administer a dose of naloxone 0.4 mg slow IV push. Change the order to every 6 hours rather than every 4 hours.

✅Administer a dose of naloxone 0.4 mg slow IV push. The priority nursing action is to administer a dose of naxalone 0.4 mg IV. For an unresponsive client, the nurse would administer naloxone 0.4 mg over a 2-minute time period to reverse the action of the opioid analgesic. The order may need to be altered or changed, but calling for a medication order change is not the first action that the nurse would take in an unresponsive client. Nurses do not change orders in terms of dosage or frequency; the health care provider changes the order. A sedated client will not be able to complete a cognitive assessment, and this action would waste time that should be spent on reversing the effects of hydromorphone Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

10 of 18 A client with terminal lung cancer is receiving hospice care at home. Which nursing action will the RN manager ask the LPN/LVN to do? Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. Teach the family to recognize signs of client discomfort such as restlessness or grimacing. Clarify family members' feelings about the meaning of client behaviors and symptoms. Develop a plan for care after assessing the needs and feelings of both the client and the family.

✅Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client for pain, shortness of breath, and nausea is appropriate to delegate to the LPN/LVN. Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

The nurse is caring for a client in a bowel retraining program. Which nursing actions will facilitate consistent defecation patterns? (Select all that apply.) Select all that apply. Use digital stimulation inserting the finger into the anus for one minute. Administer bisacodyl suppository daily. Administer the bisacodyl suppository after the client eats a meal. Encourage consumption of a high-fiber diet. Insert the bisacodyl suppository just inside the anal sphincter.

✅Administer the bisacodyl suppository after the client eats a meal. ✅Encourage consumption of a high-fiber diet. Nursing actions that are part of bowel retraining include administering a bisacodyl suppository after the client eats a meal and encouraging a high-fiber diet. The bisacodyl suppository should be administered when the client would expect to defecate, such as after a meal. High-fiber meals soften the stool and can promote regularity. Administering a bisacodyl suppository should not occur daily, rather ever second or third day to re-establish a defecation pattern. The bisacodyl suppository should be inserted past the anal sphincter against the bowel wall the stimulate rectal emptying. Digital stimulation is not the insertion of a finger into the anus, rather it is to massage the anus in a circular motion for no less than 1 minute in an attempt to trigger defecation.

A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical signs of pain. What will the nurse do next? Administer the pain medication as requested. Withhold the pain medication. Decrease the client's standard pain medication dose. Give the client a placebo and monitors the outcome.

✅Administer the pain medication as requested. The nurse will administer the pain medication as requested. Both types of persistent (chronic) pain (chronic cancer pain and chronic noncancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's objective symptoms when managing chronic cancer pain. The nurse would not decrease pain medication under the assumption that, because the client does not exhibit signs of pain, the client must not have any pain. Unless the client is involved in a clinical research trial, giving a placebo in place of medication is never appropriate. It is never appropriate to withhold prescribed pain medication unless the client is medically unstable and the nurse would contact the health care provider. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

The nurse receives the shift report. Which client would the nurse anticipate a need for arterial blood gas assessment? Admitted for excessive salicylate ingestion Admitted with chronic pancreatitis Recent diagnosis of mild chronic obstructive lung disease History of controlled type 2 diabetes

✅Admitted for excessive salicylate ingestion The client admitted for excessive salicylate (acid) would likely have an acid-base imbalance caused by salicylate intoxication. A client admitted with chronic pancreatitis is not likely to develop an acid-base imbalance so ABGs would not be indicated. The client with a history of controlled type 2 diabetes would likely not have an acid-base imbalance. Although clients with COPD are at increased risk of respiratory acidosis, a newly diagnosed client would not have an acid-base imbalance but may have a slightly decreased PaO2. MChapter 03 - Overview of Health Concepts for Medical-Surgical Nursing Concepts for Medical-Surgical Nursing

A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following? Deontology Morality Principlism Advocacy

✅Advocacy In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. A legal and ethical responsibility of nurses is to protect the rights of clients and provide safe, quality nursing care. Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a person, group, or community. The nurse made the request to remove the playground equipment on behalf of and to benefit the children of the school. This is an example of advocacy. Deontology In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. Deontology is an ethical theory based on the idea that actions must be based on moral rules or duty regardless of the consequences. The nurse's actions are not an example of deontology. Morality In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. Morality is the premise of right or wrong actions based on shared societal or generational expectations. The nurse's actions are not an example of morality. Principlism In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. Principlism is the dominant approach to ethical decision making and is comprised of the principles of respect for autonomy, nonmaleficence, beneficence, and distributive justice. The nurse's actions are not an example of principlism. NurseLogic Knowledge and Clinical Judgment Advanced

12 of 18 The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the assistive personnel to visit? Aggressive brain tumor and needs daily assistance with ambulation and bathing Advanced cirrhosis of the liver and just called the hospice agency reporting nausea Inoperable lung cancer and considering whether to have radiation and chemotherapy Prostate cancer with bone metastases and has new-onset leg weakness and tingling

✅Aggressive brain tumor and needs daily assistance with ambulation and bathing Assisting clients with activities of daily living such as ambulation and bathing is a common role for assistive personnel working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions, which are within the RN scope of practice. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

Question 13 of 13 The nurse is planning care for a client who has decreased mobility. With which interprofessional health care team members would the nurse most likely collaborate? Select all that apply. Registered dietitian nutritionist (RDN) Registered occupational therapist (OTR) Primary health care provider (PHCP) Respiratory therapist (RT) Registered physical therapist (RPT

✅All CORRECT Registered dietitian nutritionist (RDN) The nurse would likely collaborate with all of these health care team members to prevent complications of decreased mobility, and promote an increase in or maintain the current level of mobility if possible. CORRECT Registered occupational therapist (OTR) The nurse would likely collaborate with all of these health care team members to prevent complications of decreased mobility, and promote an increase in or maintain the current level of mobility if possible. CORRECT Primary health care provider (PHCP) The nurse would likely collaborate with all of these health care team members to prevent complications of decreased mobility, and promote an increase in or maintain the current level of mobility if possible. CORRECT Respiratory therapist (RT) The nurse would likely collaborate with all of these health care team members to prevent complications of decreased mobility, and promote an increase in or maintain the current level of mobility if possible. CORRECT Registered physical therapist (RPT) The nurse would likely collaborate with all of these health care team members to prevent complications of decreased mobility, and promote an increase in or maintain the current level of mobility if possible.

The nurse is in the room while the assistive personnel (AP) is providing incontinence care to a client. Which action by the AP would require the nurse to intervene? (Select all that apply.) Select all that apply. Allowing the client to remain in the same position. Applying moisture barrier cream to the perineal area. Using soap and water to clean soiled areas on the perineum. Rubbing areas on the sacrum that are slightly red. Drying the sacral area carefully with a towel. Placing a bed pillow between the client's knees.

✅Allowing the client to remain in the same position. ✅Rubbing areas on the sacrum that are slightly red. The nurse will need to intervene if the AP attempts to rub reddened areas on the client's sacrum or allows the client to remain in the same position. Rubbing reddened areas can cause additional damage to the already fragile capillary system. The client should be repositioned at least every 2 hours. Since the AP is already providing incontinence care, this is an appropriate time to reposition the client to prevent skin breakdown. It is appropriate to dry the sacral areas carefully with a towel and apply moisture barrier cream to the perineal area. This ensures that the skin is dry and protected from moisture. Using soap and water to clean soiled areas on the perineum is appropriate as it placing a bed pillow between the client's knees to avoid areas of pressure from bony prominences.

1. A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? A."This is common side effect of gabapentin and will decrease with use." B."Stop taking the medication and contact the healthcare provider." C."The dizziness is caused by the neuropathic pain, not the medication." D."The dizziness is likely from another medication, not the gabapentin.

✅Answer: A Rationale: Gabapentin is commonly used for neuropathic pain. The most common side effect is dizziness which will generally decrease with use. It is not appropriate to tell the client to stop taking the medication and it is unlikely that the neuropathic pain or another medication is causing the dizziness. Cognitive Level: Application Integrative Process: Communication and Documentation or Nursing Process Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED? A. Assess breath sounds and respiratory efforts B. Establish vascular access with a large-bore catheter C. Remove clothing to perform a complete physical assessment D. Evaluate level of consciousness (LOC) using the Glascow Coma Sale (GCS)

✅Answer: A Rationale: The highest priority action for an unconscious client who is breathing should follow the ABCDE acronym. It has been established that the client has an airway ("A"); the next priority is to assess breathing ("B"). The nurse then will establish vascular access ("C"), evaluate LOC ("D"), and perform a complete physical assessment ("E"). Cognitive Level: Analysis Client Needs Category: Safe, Effective Care Environment: Safety and Infection Control Nursing Process Step: Assessment/Evaluation Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

1.The nurse provides an SBAR handoff communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format? A.Situation B.Background C.Assessment D.Recommendation

✅Answer: A Rationale: The client's data reflects what is happening at the time of the handoff communication and reflects the Situation being shared. It is the first step in the SBAR communication. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

Physiological Integrity Which statement by a client with complete spinal cord injury resulting in paraplegia indicates understanding of a bowel retraining program? A. "I'll use a suppository to help empty my rectum." B. "I will avoid stool softeners so I don't experience diarrhea." C. "I'll eat high-fiber foods each day to help prevent constipation." D. "Digital stimulation for one full minute may be needed in order to produce stool."

✅Answer: C Rationale: Hydration, high dietary fiber, and a regular toileting routine are important interventions to promote bowel elimination for clients with paraplegia. The client who has complete paraplegia typically has a flaccid bowel indicating loss of sacral reflexes to stimulate bowel elimination. Suppositories and digital stimulation work to provide a stimulus to trigger bowel contraction and stool evacuation in clients with a spastic bowel. Therefore, using this strategy would not be successful for this client. Stool softeners should not be avoided as hard stool is common with neurologic injuries. Cognitive Level: Analyzing Integrated Process: Teaching and Learning Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

Safe and Effective Care Environment Upon entry to the ED of a client who fell from a roof, what is the nurse's priority action? A. Place nasal cannula to administer oxygen. B. Apply pressure to small bleeding wounds. C. Assess airway and stabilize cervical spine. D. Initiate large-bore IV to infuse normal saline.

✅Answer: C Rationale: The highest priority action for a client who has sustained possible life-threatening injuries is to assess the airway and stabilize the cervical spine to decrease risk for further injury. All other actions can be implemented after the airway is secured, and the cervical spine is stabilized. Cognitive Level: Analysis Client Needs Category: Safe, Effective Care Environment: Safety and Infection Control Nursing Process Step: Assessment/Evaluation Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

1.The nurse is participating in a unit meeting to discuss daily nursing care expectations. Which nursing statement reflects systems level thinking? a) "It is important to provide care consistent with the client's expectation." b) "I will always consider my client's cultural preferences when delivering care." c) "I have been comparing our rates of infection with other units in the hospital."* d) "I will look for the policy about family visitation to show my client."

✅Answer: C Rationale: Comparing rates of infection with other units shows the nurse has moved beyond the individual level of care to consider how individual care creates an environment that can be compared with other environments. Although providing care consistent with the client's expectation, considering a client's cultural preference, and educating a client about family visitation are appropriate nursing actions, they address care at the individual - not the systems - level of thinking. Cognitive Level: Application Client Needs Category: Safe, Effective Care Environment: Management of Care Nursing Process Step: Assessment/Evaluation Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

Physiological Integrity How does the presence of microRNA "silence" gene expression? A.Preventing cytoplasm from coming into contact with the gene B.Surrounding mRNA and preventing attachment of ribosomes C.Binding to mRNA and keeping it double-stranded D.Substituting a thymine for uracil

✅Answer: C Rationale: Short pieces of microRNA can bind with complementary areas of mRNA, making it double-stranded. Then areas of the gene do not get "read" during translation because the ribosomes can only bind to single-stranded RNA. This results in no functional protein being synthesized. Cognitive Level: Understanding Client needs category: Physiological Intergrity Nursing Process Step: N/A

Safe and Effective Care Environment Which client does the oncoming ED nurse see first when assigned to care for four clients? A. 21-year-old with a skin rash who has been waiting two hours to see a provider B. 30-year-old with influenza who has infusing IV fluids and is resting quietly C. 47-year-old who fell off of a curb resulting in a sprained ankle D. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior

✅Answer: D Rationale: This client should be seen first since (1) he or she has an emergent condition that could result in poor outcomes if not treated soon. Cognitive Level: Application Client Needs Category: Physiological Integrity: Physiological Adaptation Nursing Process Step: Assessment/Evaluation Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

2.The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? Select all that apply. A.Quality Improvement B.Ethics C.Health Care Disparities D.Systems Thinking E.Teamwork and Collaboration

✅Answers: A, D, E Rationale: Quality Improvement and Systems Thinking are more global concepts and usually examine care for more than one client Choices A and D). By collaborating with the dietitian, the concept of Teamwork and Collaboration apply (Choice E). From the information in the situation provided, the concepts of Ethics and Health care Disparities are not evident (Choices B and C). Copyright © 2021, Elsevier Inc. All Rights Reserved. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

8 of 18 A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem nursing action is appropriate? Removing dentures and any prosthetics Raising the head of the bed and opens the client's eyes Asking the family if they wish to help wash the client Asking the family to leave during post-death care

✅Asking the family if they wish to help wash the client The nurse may ask the family if they wish to be involved in washing the client after the client's death. The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat and the client's eyes closed. The client's dentures and prosthetics should be replaced, not removed. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

2 of 18 A client who is dying is having difficulty swallowing oral medications. Which intervention will the nurse implement for this client? Ass the provider if the medications can be discontinued or substituted. Do not administer the medications and document: "Unable to swallow." Ask the pharmacy to substitute intramuscular (IM) equivalents for the medications. Crush the pills, open the sustained-release capsules, and mix them with a spoonful of applesauce.

✅Ass the provider if the medications can be discontinued or substituted. The nurse will contact the provider to ask if the medications can be discontinued or substituted. Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort. The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

A nurse administrator is reviewing policies and procedures of the facility she works in to ensure confidentiality requirements are being met. Which of the following indicates that intervention is needed to prevent the release of confidential client information? Requiring client information be sent to providers using presaved numbers on speed dial of the fax machine Assigning staff members on each shift the same password for accessing medical records Allowing nurses to complete electronic documentation on a client while at the client's bedside Discussing a client's financial hardship at an interdisciplinary team meeting

✅Assigning staff members on each shift the same password for accessing medical records In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to determine the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. Each staff member should have a personal password that is not shared with others and is used to enter and sign-off of computerized records. Individuals caring for a client should be the only ones able to access client records. If all staff members on each shift have the same password, limitations exist in tracking who is accessing those records, increasing the possibility that someone not involved in the care of a client could access records out of curiosity. This procedure is not appropriate and requires intervention to prevent the release of confidential information. Requiring client information be sent to providers using presaved numbers on speed dial of the fax machine In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to determine the one that results in a breach of confidentiality. Having fax numbers presaved on the fax machine eliminates the possibility of an entry-error when sending client information to providers. This procedure is appropriate and does not require intervention to prevent the release of confidential information. Allowing nurses to complete electronic documentation on a client while at the client's bedside In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to determine the one that results in a breach of confidentiality. The completion of electronic documentation while at the client's bedside is a common occurrence, and the client has the right to view any information included in the medical record. The nurse should be aware if visitors are present in the room, ensuring the monitor cannot be seen and that any discussions with the client do not include confidential information. This procedure is appropriate and does not require intervention to prevent the release of confidential information. Discussing a client's financial hardship at an interdisciplinary team meeting In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to determine the one that results in a breach of confidentiality. The interdisciplinary team consists of a team of health care professionals involved in the care of the client. Discussions include anything of concern that can have an impact on the client's health. This procedure is appropriate and does not require intervention to prevent the release of confidential information. NurseLogic Knowledge and Clinical Judgment Advanced

A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. The client reports a burning pain in his chest. Which of the following actions by the nurse is appropriate? Assist the client to a side-lying position. Remove 10 mL of water from the suction control chamber. Apply a padded clamp on the tubing for 1 to 2 min. Move the drainage system above the level of the client's heart.

✅Assist the client to a side-lying position. In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Burning sensation or pain can result from the chest tube becoming occluded because it is resting against tissue. It is possible to move the tip of the chest tube away from the tissues by repositioning the client. Repositioning the client is the appropriate action by the nurse. Remove 10 mL of water from the suction control chamber. In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. An air vent is created for the chest drainage system by placing an open tube in the water of the suction control chamber. The depth of this open tube in the water controls the amount of suction in the drainage system and should be maintained at the level prescribed by the provider. Removing 10 mL of water from the suction control chamber is not an appropriate action by the nurse. Apply a padded clamp on the tubing for 1 to 2 min. In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. A padded clamp may be applied briefly to the tubing if continuous bubbling is noted in the water seal chamber or if prescribed by the provider. When a padded clamp is applied close to the occlusive dressing and air bubbling in the chamber continues, the air leak is between the clamp and the chest drainage system. If the bubbling in the chamber stops when a padded clamp is applied, the air leak is likely at the chest tube insertion site or within the chest. Clamping the tube should be brief to prevent a tension pneumothorax. Applying a padded clamp on the tubing for 1 to 2 min is not an appropriate action by the nurse. Move the drainage system above the level of the client's heart. In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. To prevent fluids from flowing back into the pleural space, the chest drainage system must be kept at a level below the client's chest. Moving the drainage system above the level of the client's heart is not the appropriate action by the nurse. NurseLogic Knowledge and Clinical Judgment Advanced

A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? To the left To the right Away from the body Toward the body

✅Away from the body To answer this item, you need knowledge of sterile procedures. This item required foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination. During such procedures, any sterile item that comes into contact with an unsterile object is considered contaminated. To prevent contamination of the sterile field, nurses follow certain steps when opening sterile packages and creating a sterile field. Opening the sterile package away from the body first allows a nurse to open the remaining flaps without reaching over the sterile field, which could result in contamination. This is the appropriate direction to open the sterile package. To the left To answer this item, you need knowledge of sterile procedures. This item required foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination. During such procedures, any sterile item that comes into contact with an unsterile object is considered contaminated. To prevent contamination of the sterile field, nurses follow certain steps when opening sterile packages and creating a sterile field. Opening the sterile package to the left first makes it challenging to open remaining flaps without reaching over the sterile field, which results in contamination. This is not the appropriate direction to open the sterile package. To the right To answer this item, you need knowledge of sterile procedures. This item required foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination. During such procedures, any sterile item that comes into contact with an unsterile object is considered contaminated. To prevent contamination of the sterile field, nurses follow certain steps when opening sterile packages and creating a sterile field. Opening the sterile package to the right first makes it challenging to open remaining flaps without reaching over the sterile field, which results in contamination. This is not the appropriate direction to open the sterile package. Toward the body To answer this item, you need knowledge of sterile procedures. This item required foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination. During such procedures, any sterile item that comes into contact with an unsterile object is considered contaminated. To prevent contamination of the sterile field, nurses follow certain steps when opening sterile packages and creating a sterile field. Opening the sterile package toward the body first makes it challenging to open remaining flaps without reaching over the sterile field, which results in contamination. This is not the appropriate direction to open the sterile package.

The nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data? "I had three glasses of champagne at my granddaughter's wedding last month." "I am a 'teetotaler'; I never drink anything alcoholic." "I like to have a glass of wine every once in a while." "I usually drink two vodkas to help me get to sleep each night."

✅CORRECT "I usually drink two vodkas to help me get to sleep each night." The recommended alcohol intake (National Institute on Alcohol Abuse and Alcoholism) for people over 65 years of age is one drink daily or seven drinks weekly. The practice of drinking two vodkas daily exceeds those recommendations and needs to be followed up by the nurse. Although it is impossible to determine whether someone who abstains from alcohol is an alcoholic, many people choose not to drink any alcohol at all. Unless evidence is available to dispute, the client who is a "teetotaler" should be believed. An occasional drink of an alcoholic beverage is within the range of normal consumption for older adults. Unless other alcohol was reported and is used more routinely, the level of consumption for the other clients should cause no alarm on a routine assessment. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

The RN is arriving for night shift at an acute care hospital. Which client does the RN assess first? A 70 year old with a history of gout and joint pain A 72 year old admitted with postoperative delirium A 65 year old scheduled for next-day surgery A 68 year old with chronic protein-calorie malnutrition

✅CORRECT A 72 year old admitted with postoperative delirium The postoperative client with delirium is at risk for injury because associated agitation and/or combativeness may lead to behaviors such as climbing out of bed or pulling at invasive catheters. Clients such as a 65 year old scheduled for next-day surgery, a 68 year old with chronic protein-calorie malnutrition, or a 70 year old with a history of gout and joint pain need to be assessed as soon as possible, but scheduled surgery, malnutrition, and a diagnosis of gout with joint pain do not indicate any acute risk for complications. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

Question 1 of 13 The nurse requests a conference with members of the interprofessional health care team regarding care for a complex client. Which Interprofessional Education Collaborative Competency does this request represent? Role-Responsibilities Interprofessional Communication Values/Ethics for Interprofessional Practice Teams and Teamwork

✅CORRECT Interprofessional Communication The competency of Interprofessional Communication is the ability to communicate with patients, families, and other health professionals in a way that supports a team approach to maintaining health and managing health problems. Values/Ethics relates to respect for the health care team, Role-Responsibilities uses knowledge of one's own role to manage patients, and Teams and Teamwork involves actual delivery of care with the health team. Role-Responsibilities The competency of Interprofessional Communication is the ability to communicate with patients, families, and other health professionals in a way that supports a team approach to maintaining health and managing health problems. Values/Ethics relates to respect for the health care team, Role-Responsibilities uses knowledge of one's own role to manage patients, and Teams and Teamwork involves actual delivery of care with the health team. Values/Ethics for Interprofessional Practice The competency of Interprofessional Communication is the ability to communicate with patients, families, and other health professionals in a way that supports a team approach to maintaining health and managing health problems. Values/Ethics relates to respect for the health care team, Role-Responsibilities uses knowledge of one's own role to manage patients, and Teams and Teamwork involves actual delivery of care with the health team. Teams and Teamwork The competency of Interprofessional Communication is the ability to communicate with patients, families, and other health professionals in a way that supports a team approach to maintaining health and managing health problems. Values/Ethics relates to respect for the health care team, Role-Responsibilities uses knowledge of one's own role to manage patients, and Teams and Teamwork involves actual delivery of care with the health team. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative interventions will be most helpful for them? (Select all that apply.) Select all that apply. Joining a peer group with a common learning goal Meditating for 30 minutes every day Allowing for increased rest and relaxation time Having solitary times to reminisce about life experiences Starting a new physical activity Learning a new skill

✅CORRECT Joining a peer group with a common learning goal ✅Starting a new physical activity CORRECT ✅Learning a new skill Cognitive health problems (depression, delirium, and dementia) can be offset by social engagement with a peer group, learning a new skill, and physical activity. Increased rest time, meditation, and increased solitude may be helpful for other aspects of aging but do not benefit the older adult's cognitive capabilities. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

Question 18 of 19 The nurse recognizes that older adult clients when admitted to the hospital are at high risk for complications and even death. Which risk factors are considered "markers" that can contribute to these negative outcomes? (Select all that apply.) Select all that apply. Sleep disorders Falls Nutritional problems Confusion Incontinence

✅CORRECT Sleep disorders . ✅ Falls ✅ Nutritional problems " ✅ Tool. ✅ Incontinence All of these evidence-based risk factors, or "markers" can increase hospital stays, lead to complications, and hasten death of older adults and are used as a basis for Fulmer's SPICES Assessment Tool. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

The medical-surgical nurse is coordinating transfer from acute care to community-based care for a client who requires rehabilitation. Which interprofessional team members will be the primary decision makers in this transition? Medical-surgical nurses Rehabilitation nurses Client and family Case managers

✅Client and family Client and family will be the primary decision makers in this transition. Clients in a rehabilitation setting are managed by an interprofessional team, but the client and client's family are at the center of the team and should be the primary decision makers. The case manager, the medical-surgical nurse, and the rehabilitation nurse are important members of the interprofessional team, but are not the most important members Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

The nurse is teaching a class on clinical judgment. What teaching will the nurse include? Clinical judgment is a fixed process. Clinical judgment is not required to make an informed decision. Clinical judgment is an outcome of critical thinking. Clinical judgment happens outside the context of the scenario.

✅Clinical judgment is an outcome of critical thinking. Clinical judgment, as defined by the National Council of State Boards of Nursing, is the observed outcome of critical thinking and decision making. It is an iterative process (not fixed) that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

Which nursing action reflects Assessing, per the AAPIE model of Assessing, Analyzing, Planning, Implementing, and Evaluating? (Select all that apply.) Select all that apply. Administers IV furosemide 40 mg as prescribed. Sets a goal for client to resume normal activities within 4 weeks following surgery. Compares temperature at 0600 with temperature taken at 1200. Contacts health care provider after obtaining blood pressure of 200/100. Collects information about how client sustained an injury. Notes pressure injury of 2 inches by 1 inch on sacrum.

✅Collects information about how client sustained an injury. ✅Notes pressure injury of 2 inches by 1 inch on sacrum. Assessment involves observing what the client says subjectively, and what the nurse observes objectively. Collecting information about how a client sustained an injury and noting a pressure injury are examples of assessment. Comparing temperature readings reflects evaluating. Setting a goal for a client reflects planning. Administering medication reflects implementing. Contacting a health care provider after determining a blood pressure reading is high reflects analyzing, and then implementing. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

Question 4 of 15 The nurse is designing a program to make vaccines available to as many people as possible. Into which environment is the vaccine most likely to be introduced first? A. Medical home B. Inpatient care C. Long-term care D. Community Health Center

✅Community Health Center Community health care incorporates the model of primary care delivery with a population-based approach. It is within this system of care, at the community health center level, that the most people can be immediately reached in order to receive a new vaccine first. Later, the vaccine may be introduced at specialized points of care such as inpatient care, long-term care, and the medical home. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

Question 15 of 19 Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain

✅Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care would be assigned to the LPN/LVN. LPN/LVN education and scope of practice include working within practice parameters to administer pain medication and to perform dressing changes. Assessments and client education are not within the LPN/LVN scope of practice. Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

The nurse notes that a client has a pale cool left leg without palpable pulses. What would be the nurse's best action at this time? Continue to monitor the client's left leg. Document the assessment findings. Contact the Rapid Response Team (RRT). Elevate the client's left leg.

✅Contact the Rapid Response Team (RRT). The client is displaying the signs and symptoms of an acute arterial clot that is preventing adequate perfusion to the left leg. This is an emergent situation which requires the nurse to contact the RRT immediately Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure injuries, and limb contractures. What would the nurse do first? Contact the hospital social worker. Ask the daughter about the ulcers and contractures. Notify the primary health care provider. Give the client a bath.

✅Contact the hospital social worker. The social worker will assess the client's situation and will contact the appropriate authorities if needed. Asking the daughter sets up a potential confrontation that need not be handled by the nurse. The client needs a bath, but this is not the first action to be taken. Notifying the primary health care provider will be appropriate at a later time, but is not the best action to take at this point. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

As the nurse gives a client the informed consent form to sign, the client asks, "Now what exactly are they going to do to me?" What is the appropriate nursing action? Have the client sign the form. Contact the anesthesiologist. Contact the surgeon. Explain the procedure

✅Contact the surgeon. The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience. The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed. It is not appropriate to have the client sign the form until the surgeon has clarified the procedure with the client Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pin-prick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present

✅Correct Answer: A Rationale: After general anesthesia, which affects the entire body, the priority assessment is to determine that the client's level of consciousness has returned. All other assessment can be performed subsequently. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Implementation Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Physiological Integrity: Reduction of Risk Potential The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A. "When I eat shrimp, my tongue swells and I have trouble breathing." B."I'm feeling more anxious about my surgery than I thought I would be." C."I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she did not like the way she felt."

✅Correct Answer: A Rationale: An allergy to iodine or shellfish indicates a risk for a reaction to the agents used to clean the surgical area. With this knowledge about the client, the nurse must intervene immediately. All other statements can be responded to after addressing the shrimp allergy. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Implementation Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Physiological Integrity: Reduction of Risk Potential In the early postoperative period, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

✅Correct Answer: A Rationale: An increase in back pain can be indicative of an epidural hematoma; therefore, the nurse will immediately address this finding. Blood pressure can be compared to baseline after addressing the back pain, as can the headache. The nurse can continue to monitor the expected, gradual return of motor function. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Assessment Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D."Let's try some relaxation exercises to help address the discomfort you are feeling."

✅Correct Answer: B Rationale: The nurse will assess the client's level of pain to determine whether it is increasing, unmanaged, or able to be managed until the next dose of medication is due. Telling the client they cannot have medication for another hour, without conducting an assessment, is inappropriate, as cues to a changing health status could be missed. Starting a pain diary may be an appropriate intervention at a later time, but does not address the client's immediate concern. Providing relaxation exercises may be appropriate, but only after an assessment is conducted to determine the cause of the client's pain. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Implementation Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Psychosocial Integrity A client whose father has Huntington's disease (HD) has been told that by his father's neurologist that genetic/genomic testing for this disorder is possible. He is frightened of knowing for certain he may develop a disabling disease for which there is no cure. He asks a nurse what she would do if one of her parents had the disease. Which responses are the most ethical for the nurse to provide to this client? Select all that apply. A. "I would have the test so I could decide whether to have biological children." B. "Although I can tell you the benefits and the risks of testing, you must make this decision yourself." C. "Because there is no cure for this disease and testing would not be beneficial, I would not have the test." D. I would only have testing if my parent had an early onset of the disease and experienced rapid deterioration." E. "You need to check with your primary health care provider to determine whether testing for this disease would be appropriate for you." F. "You sound conflicted. Would you like me to put you in contact with a genetics counselor who can provide you with the most up-to-date information?

✅Correct Answer: B, F Rationale: Any level of genetic counseling requires the health care professional to be "nondirective." If the client has spoken only to nongenetic professionals, he would likely be helped by a consultation with a certified genetics counselor. Even then, the counselor must ensure that the client has adequate and accurate information upon which to base the decision but cannot suggest or direct the client to test or not to test. The client may wish to discuss the issue with his or her health care providers and family, but ultimately, the decision about testing can only be made by the client. Cognitive Level: Applying or higher Client needs category: Psychosocial Integrity Nursing Process Step: Implementation Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

1.Which activity would a medical-surgical nurse be expected perform as part of client focused genomic care? A. Calculating recurrence risk for a woman who was recently diagnosed with unilateral breast cancer. B. Informing a client that his or her genetic/genomic testing results are positive for a genetic disorder. C. Obtaining an accurate family history and physical assessment data. D. Requesting a consultation visit from a clinical geneticist.

✅Correct Answer: C Rationale: This question relates to a nurse evaluating his or her scope of practice and limitations within genomic care. Being able to organize a family history into a pedigree is an important skill for all health professionals and an expectation for all registered nurses with a bachelor's degree in nursing (BSN). The American Association of Colleges of Nursing have included in their document Essentials of Baccalaureate Education for Professional Nursing Practice 2008 that all BSN graduates must be able to "generate a pedigree from a three-generation family history using standardized symbols and terminology." Calculating recurrence risk or odds ratios for a genetic disorder in not within the scope of practice for a generalist medical-surgical nurse. It is important that the nurse not attempt to provide genetic counseling as this is beyond his or her scope of practice; however, it is helpful to have a good sense of when referral should be considered even though a medical-surgical nurse does not directly perform referrals to genetic professionals. Cognitive Level: Applying or higher Client needs category: Safe and Effective Care Environment Nursing Process Step: Assessment Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

Physiological Integrity: Reduction of Risk Potential The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A.Left arm prosthesis B.Skin turgor < 3 seconds C.Blood pressure 160/100 D.Presence of chest rigidity E.Has been NPO since midnight F.Expressed concern about surgery payment

✅Correct Answers: A, C, D Rationale: The nurse will report assessment findings of a left arm prosthesis (as this must be addressed prior to surgery); blood pressure of 160/100 (as this is high, which may delay surgery); and the presence of chest rigidity (which is an abnormal finding that may indicate respiratory compromise which could affect whether surgery takes place) to the operative team. The findings of skin turgor of < 3 seconds, adherence to the NPO plan, and a natural concern about payment for surgery do not require reporting to the operative team. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Implementation Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

Safe and Effective Care Environment What mechanism of injury will the nurse document for a client in a motor vehicle accident whose airbag deployed when the car struck a tree at 40 miles per hour? Select all that apply. A. Blast B. Blunt C. Laceration D. Penetration E. Acceleration-deceleration

✅Correct Answers: B, E Rationale: Blunt trauma has been sustained from the airbag deployment. Acceleration-deceleration trauma has been sustained from the car striking the tree. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Physiological Adaptation Nursing Process Step: Assessment/Evaluation Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

Physiological Integrity: Reduction of Risk Potential The nurse is caring for a client who is to undergo surgery at 6:00 AM today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso* D. Took 650 mg of aspirin yesterday* E. Has not had food nor water since 9:00 PM last night

✅Correct Answers: C, D Rationale: A diffuse rash could be an indication of a health deviation that must be assessed before surgery. Taking aspirin (or any other medication that anticoagulates) is generally not permitted for a certain period of time before surgery. Therefore, the nurse will notify the surgeon and anesthesia provide of both of these assessment findings. A blood pressure of 130/72 and a serum potassium of 3.5 mEq/L are normal findings, as is the adherence of the client who has not had food nor water for the recommended time before surgery. Cognitive Level: Analysis Client Needs Category: Physiological Integrity: Reduction of Risk Potential Nursing Process Step: Assessment

Psychosocial Integrity The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

✅Correct Answers: C, D, E Rationale: The nurse will use therapeutic communication to determine the client's underlying concerns. This is accomplished by asking the client if there has been a past history of drug dependence (which may explain the reluctance), what seems most fearful about taking opioids (which gives the nurse the chance to dispel myths), and teaching that there are proper ways of taking opioids (as directed and for a short period of time) that is meant to keep the client from becoming dependent. Asking "why" is nontherapeutic and can shut down the line of communication between the client and nurse, as this approach demands a response. The nurse will not promise to give the patient opioids at this time, as further investigation of the client's concerns are warranted first. Cognitive Level: Analysis Client Needs Category: Psychosocial Integrity Nursing Process Step: Implementation Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take? Reposition the client every 4 hr. Cover the area with a transparent wound barrier. Massage areas surrounding the redness. Wash the area with hot water every 8 hr.

✅Cover the area with a transparent wound barrier. In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. This item requires foundational thinking because you have to recall interventions that are appropriate for maintaining skin integrity in clients who are immobile. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1 pressure ulcer. A transparent wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent contamination and reduce friction to the area is an appropriate action by the nurse. Reposition the client every 4 hr. In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. This item requires foundational thinking because you have to recall interventions that are appropriate for maintaining skin integrity in clients who are immobile. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1 pressure ulcer. Clients at risk for or with impaired skin integrity should be repositioned every 2 hr instead of every 4 hr to prevent further damage to the tissues; therefore, this is not an appropriate action by the nurse. Massage areas surrounding the redness. In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. This item requires foundational thinking because you have to recall interventions that are appropriate for maintaining skin integrity in clients who are immobile. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1 pressure ulcer. Massaging area surrounding the reddened area can result in trauma to the deep tissues and should be avoided by the nurse. Wash the area with hot water every 8 hr. In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. This item requires foundational thinking because you have to recall interventions that are appropriate for maintaining skin integrity in clients who are immobile. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1 pressure ulcer. Washing the area with hot water should be avoided because it can cause further irritation and increase skin dryness; therefore, this is not an appropriate action by the nurse. NurseLogic Knowledge and Clinical Judgment Beginner

Which action does the nurse implement for a client with wound evisceration? Irrigate the wound with warm, sterile saline. Cover the wound with a sterile, warm, moist dressing. Replace tissue protruding into the opening. Apply direct pressure to the wound.

✅Cover the wound with a sterile, warm, moist dressing. Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Evisceration occurs when a wound opens up and body organs are exposed. Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection. Chapter 09 - Concepts of Care for Perioperative Patients Medical-Surgical Nursing

The nurse is preparing to give multiple prescribed medications to an older adult client. Which serum laboratory test value would the nurse review as the priority prior to medication administration? Blood urea nitrogen Hematocrit Creatinine Sodium

✅Creatinine Most drugs are excreted via the kidneys so it is important that the client has adequate kidney function. Creatinine is a protein waste product that is excreted by the kidneys with only a small amount remaining in the bloodstream. Therefore, it is the most important laboratory test value to review. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

Which electrolyte laboratory result for a presurgical client will the nurse report to the anesthesiologist? (Select all that apply.) White blood cell count 14,000 mm3 Potassium, 3.9 mEq/L (3.9 mmol/L) Creatinine, 1.9 mg/dL (168 mcmol/L) Fasting glucose, 80 mg/dL (4.4 mmol/L) Sodium, 140 mEq/L (140 mmol/L)

✅Creatinine, 1.9 mg/dL (168 mcmol/L) The nurse will report a creatinine of 1.9 mg/dL (168 mcmol/L) and a white blood cell count of 14,000 mm3 to the anesthesiologist. These values are outside of the expected normal ranges and may indicate renal problems (creatinine) and infection (white blood cell count). A fasting glucose of 80 mg/dL (4.4 mmol/L), a potassium level of 3.9 mEq/L (3.9 mmol/L), and sodium level of 140 mEq/L (140 mmol/L) are normal laboratory values.

A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness? Rapid weight gain Tar-colored stools Lethargy Dark urine

✅Dark urine In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree. The biliary tree begins as many small ducts that join together into one main common bile duct, similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to the small intestine where bacteria break it down into urobilinogen to be excreted in the feces. Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the liver and being excreted in the urine. The nurse should teach the parent that dark urine is a clinical manifestation associated with the illness. Rapid weight gain In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree. The biliary tree begins as many small ducts that join together into one main common bile duct, similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to the small intestine where bacteria break it down into urobilinogen to be excreted in the feces. Because of the progressive damage to the biliary tree, bile delivered to the small intestine is reduced, altering the metabolism of fats in infants who are diagnosed with biliary atresia. This difficulty in metabolizing fat leads to poor weight gain, instead of rapid weight gain. The nurse should not teach the parent that rapid weight gain is a clinical manifestation associated with the illness. Tar-colored stools In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree. The biliary tree begins as many small ducts that join together into one main common bile duct, similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to the small intestine where bacteria break it down into urobilinogen to be excreted in the feces. The nurse should not teach the parent that tar-colored stools are a clinical manifestation associated with the illness. White or tan stools, not tar-colored stools, are a clinical sign of biliary atresia because of the lack of bilirubin in the intestinal tract. Lethargy In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Irritability, not lethargy, is a clinical sign of biliary atresia. It is often difficult to console or comfort infants who are diagnosed with biliary atresia. The nurse should not teach the parent that lethargy is a clinical manifestation associated with the illness.

The son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. After noting the son's comments and assessing the client, which cognitive problem does the nurse suspect the client may have? Depression Delirium Drug adverse effects Dementia

✅Dementia Dementia is a broad term used for a syndrome that involves a slowly progressive cognitive decline and recent progressive periods of forgetfulness. It is sometimes referred to as chronic confusion. Drug adverse effects will be related to a specific medication and not appear progressively over time. Further cognitive and medical/neurologic testing would be needed to establish this diagnosis, which would not be done by a nurse. Delirium is an acute state of confusion, which differs from dementia in that it is usually short term and reversible within 3 weeks. It is often seen in older adults when they are in an unfamiliar setting. Depression is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

The nurse is caring for an older adult client who has been under the care of a psychiatrist for 10 years. What is the most commonly occurring mental health disorder in the older adult population? Dementia Depression Bipolar disorder Delirium

✅Depression Depression is the most common mental health disorder, both primary and secondary types. Common factors that predispose this group to this disorder include loss and loneliness. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

Question 1 of 15 Which nursing action reflects the process of prioritize hypotheses, per the NCSBN Clinical Judgement Measurement Model (CJMM)? A. Determining that a new blood pressure reading of 190/100 requires intervention now B. Obtaining vital signs every 4 hours and noting a client's blood pressure as 130/90 C.Administering amlodipine 5 mg orally once daily D. Contacting the registered dietician nutritionist (RDN) to evaluate a client's salt intake

✅Determining that a new blood pressure reading of 190/100 requires intervention now Prioritizing hypotheses is the act of considering all possibilities and determining their relative urgency and risk to the client. The nurse who has determined that a blood pressure reading of 190/100 requires nursing intervention now has performed prioritization. Administering medication and contacting a member of the interprofessional health care team reflects the CJMM process of take action. Obtaining vital signs and noting the reading reflects the CJMM process of recognize cues. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

Question 2 of 15 Which client situation reflects the health care system of managed care? A. A client obtains vaccinations at a local community health center that is close to home. B. A client receives an annual physical where the cost has been predetermined as $80. C. A client sees a designed family physician who coordinates all aspects of the client's care. D. A client with abdominal pain is admitted to a hospital for 24 hours of observation.

Question 6 of 15 Which nursing action reflects systems thinking? A. Giving report to the next shift including client status B. Developing a quality improvement initiative for respiratory assessment C. Documenting the client's lung sounds each shift D. Reviewing best practice for respiratory assessment

✅Developing a quality improvement initiative for respiratory assessment The goal of systems thinking is to encourage the nurse to develop awareness of the interrelationships that exist between individual care and the overall context of health care safety and quality improvement. Documenting and reporting affect individual patient care. Reviewing best practice reflects improving individual nurse practice. Quality improvement initiatives address the systems level, working to improve assessment within an entire unit and/or facility. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

Question 12 of 19 The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a total hip arthroplasty. With Beers Criteria used as a resource, which drug poses a potential risk for this client? Acetaminophen Digoxin Celecoxib Mesalamine

✅Digoxin Beers Criteria is a guideline for health care professionals to help improve the safety of prescription medications for older adults. It involves potentially inappropriate medication use in older adults. Digoxin is listed in the Beers Criteria as a drug that leads to toxicity and drug interaction problems. Clients receiving this medication are at greater risk for serious side effects and interactions. Acetaminophen, celecoxib, and mesalamine are not listed in the Beers Criteria as drugs that lead to toxicity and drug interaction problems. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider? Silver-colored striae Unilateral nipple inversion present since menarche Dimpling of the tissue in the upper outer quadrant Visible symmetrical venous patterns

✅Dimpling of the tissue in the upper outer quadrant In this item, you need nursing knowledge related to data collection of the breasts and knowledge of deviations from the expected that are indicative of cancer. Based on an understanding of these concepts, you can identify which option describes a finding that is not within the expected range and can indicate a cancerous lesion. This item requires foundational thinking because you have to identify which finding is outside the expected range. Dimpling of the tissue in the upper outer quadrant should be considered an unexpected finding and reported to the provider. In fact, dimpling that is noted anywhere within the breast tissue should be reported. Dimpling makes the tissue appear retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor. This variation of the breast tissue is consistent with breast cancer. Silver-colored striae In this item, you need nursing knowledge related to data collection of the breasts and knowledge of deviations from the expected that are indicative of cancer. Based on an understanding of these concepts, you can identify which option describes a finding that is not within the expected range and can indicate a cancerous lesion. This item requires foundational thinking because you have to identify which finding is outside the expected range. Silver-colored striae should be considered an expected finding and does not need to be reported to the provider. This variation of the breast tissue is the result of stretch marks caused by rapid growth of the breast tissue and is not considered a variation from the expected. Unilateral nipple inversion present since menarche In this item, you need nursing knowledge related to data collection of the breasts and knowledge of deviations from the expected that are indicative of cancer. Based on an understanding of these concepts, you can identify which option describes a finding that is not within the expected range and can indicate a cancerous lesion. This item requires foundational thinking because you have to identify which finding is outside the expected range. Unilateral nipple inversion present since menarche should be considered an expected finding for the client and does not need to be reported to the provider. New onset nipple inversion should be reported as it can indicate underlying disease; however, nipple inversion in one or both nipples that has been present since puberty should not be considered a variation from the expected. Visible symmetrical venous patterns In this item, you need nursing knowledge related to data collection of the breasts and knowledge of deviations from the expected that are indicative of cancer. Based on an understanding of these concepts, you can identify which option describes a finding that is not within the expected range and can indicate a cancerous lesion. This item requires foundational thinking because you have to identify which finding is outside the expected range. Visible symmetrical venous patterns should be considered an expected finding and does not need to be reported to the provider. This manifestation is often noted in thin, pregnant, or light-skinned women. Because the venous pattern is symmetrical, this should not be considered a variation from the expected; however, venous patterns that are unilateral, or hypervascular areas caused by an increased blood flow, should be reported to the provider. NurseLogic Knowledge and Clinical Judgment Beginner

A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor? Faxing laboratory results to a client's provider Discussing changes in a client's plan of care with his friend who is a nurse on another unit Describing a client's level of independence to the case manager arranging home health services Remaining in the room with the client while he reviews his own medical records

✅Discussing changes in a client's plan of care with his friend who is a nurse on another unit In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention by the nurse preceptor is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to interpret the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. A nurse discussing changes in a client's plan of care with another nurse on another unit is a breach of confidentiality. Client information can only be shared with other health care professionals involved in that client's care. The nurse on the other unit should be directed to the client to request information about changes in the client's plan of care. This action is not appropriate and requires intervention by the nurse preceptor. Faxing laboratory results to a client's provider In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention by the nurse preceptor is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to interpret the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. Faxing laboratory results to a client's provider is not a breach in confidentiality. The provider is involved in the client's care and review of the lab work can impact currently prescribed interventions. When faxing client information, the nurse should verify the fax number, use a cover sheet with a confidentiality statement, and verify receipt of the document with the provider's office. This action is appropriate and does not require intervention by the nurse preceptor. Describing a client's level of independence to the case manager arranging home health services In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention by the nurse preceptor is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to interpret the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. Describing a client's level of independence to the case manager arranging home health services is not a breach in confidentiality. The case manager is directly involved in caring for the client and needs this information to determine which home care services are most appropriate. This action is appropriate and does not require intervention by the nurse preceptor. Remaining in the room with the client while he reviews his own medical record In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention by the nurse preceptor is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to interpret the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. Remaining in the room with the client while he reviews his own medical records is not a breach in confidentiality. According to HIPAA, clients have the right to review and request copies of medical records, as well request amendments of those medical records. Policy and procedure regarding these rights of the client varies by facility and can include remaining with the client as he reviews his records. This action is appropriate and does not require intervention by the nurse preceptor. NurseLogic Knowledge and Clinical Judgment Beginner

17 of 18 The nurse is caring for a client who is actively dying. What nursing action is appropriate? (Select all that apply.) Select all that apply. Do not encourage the client to stay awake. Offer to insert a Foley catheter for comfort. Place warm blankets on the client to keep them warm. Use moist swabs to keep the mouth and lips moist. Encourage the client to eat ice chips and drink as much as possible. Make sure the room is well-lit.

✅Do not encourage the client to stay awake. ✅Offer to insert a Foley catheter for comfort. ✅Use moist swabs to keep the mouth and lips moist. When caring for a client who is actively dying, the skin may become cold and mottled. Do not apply heating blankets. Using moist swabs will help to keep the client's mouth and lips more comfortable. The room should be dimly lit, with minimal noise and stimulation. The client should be offered ice chips or drink but do not force to drink as much as possible. Allow the client to rest, do not force them to stay awake. The nurse can offer a Foley catheter for comfort. Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

An 80-year-old client has limited mobility following a stroke. Which nursing intervention will help prevent skin breakdown? Applying moist packs to the skin every shift Decreasing calories consumed; avoiding weight gain Turning and repositioning at least every 4 hours Ensuring the client's skin remains dry and clean

✅Ensuring the client's skin remains dry and clean The nurse ensures that the client's skin stays dry and clean to prevent skin breakdown. Keeping the client's skin clean and dry will ensure early detection and prevention of the problem. Moisture is contraindicated because it can cause further skin breakdown. Decreasing calories is contraindicated because nutrition is needed for good skin turgor; weight gain is likely not an issue for this client. The client should be repositioned at least every 2 hours to prevent skin breakdown. Chapter 07 - Concepts of Rehabilitation for Chronic and Disabling Health Problems Medical-Surgical Nursing

Question 14 of 15 The nurse is discussing how context influences clinical judgment. What nursing considerations reflect context? (Select all that apply.) Select all that apply. Environment of care Taking a client's temperature Availability of electronic health records Time pressures within the unit Individual nursing knowledge

✅Environment of care ✅Availability of electronic health records ✅Time pressures within the unit ✅Individual nursing knowledge The most important part of the CJMM is that another layer—the context of the situation—considers and supports clinical judgment. The factors within this layer, such as environment, time pressure, availability or content of electronic health records, resources, and individual nursing knowledge, have a direct impact on clinical judgment. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

7 of 18 The nurse is coordinating interprofessional palliative care interventions for the client who is dying. Which goal is the nurse seeking to meet? Facilitating a peaceful death for the client Ensuring an expedited death Meeting all of the client's needs Avoiding symptoms of client distress

✅Facilitating a peaceful death for the client Facilitating a peaceful death for the client is one of the goals of palliative care. Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life). Chapter 08 - Concepts of Care for Patients at End of Life Medical-Surgical Nursing

A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication? Hypothermia Polyuria Headache Seizures

✅Headache To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Lumbar punctures are performed to withdraw cerebrospinal fluid found in the subarachnoid space for analysis. This is accomplished by inserting a needle into the lumbar subarachnoid space, typically between the third and fourth or fourth and fifth lumbar vertebrae. After the cerebrospinal fluid specimen has been removed, it is not uncommon for leakage of cerebrospinal fluid to continue at the puncture site. The leakage of cerebrospinal fluid leads to insufficient cerebrospinal fluid in the brain, which causes an inability to maintain appropriate mechanical stabilization of the brain. A headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture that results from cerebrospinal fluid leakage at the puncture site. These headaches are managed primarily with analgesics, hydration, and bed rest. Seizures To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Seizures are not a manifestation that results from cerebrospinal fluid leakage at the puncture site following a lumbar puncture. Instead, a lumbar puncture can be performed in an attempt to determine the cause of seizures. Hypothermia To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Hypothermia is not a manifestation that results from cerebrospinal fluid leakage at the puncture site following a lumbar puncture. Instead, the client can experience a slightly elevated temperature. Polyuria To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Polyuria is not a manifestation that results from cerebrospinal fluid leakage at the puncture site following a lumbar puncture. Instead, the client can experience difficulty voiding. NurseLogic Knowledge and Clinical Judgment Advanced

An older adult client admitted to the hospital for heart failure has a history of a fractured hip due to a previous fall. The client is taking hydrocodone-acetaminophen as needed for pain secondary to an extensive dental procedure. Which risk factor puts this client at greatest risk for a fall? History of a fall Age Opioid use Diagnosis

✅History of a fall The client's recent history of falling is the single most important predictor for falls. Adults age 80 years and older and those with multiple diagnoses are at higher risk for falls. Opioids may cause mental changes, but this is not the greatest risk for a fall. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? Hypomagnesemia Hyperglycemia Hyponatremia Hyperkalemia

✅Hyperglycemia In this item, you need nursing knowledge of dexamethasone to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of dexamethasone. Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. Hyperglycemia, an elevated blood glucose level, is an adverse effect of dexamethasone. Both hyperglycemia and glycosuria can be manifested in clients who are taking dexamethasone because of its effect on the production and use of glucose. Hypomagnesemia In this item, you need nursing knowledge of dexamethasone to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of dexamethasone. Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. Hypomagnesemia, a low level of magnesium in the blood, is not an adverse effect of dexamethasone. Hyponatremia In this item, you need nursing knowledge of dexamethasone to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of dexamethasone. Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. Hyponatremia, a low level of sodium in the blood, is not an adverse effect of dexamethasone. Hyperkalemia In this item, you need nursing knowledge of dexamethasone to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of dexamethasone. Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. Hyperkalemia, an elevated level of potassium in the blood, is not an adverse effect of dexamethasone.

The nurse is caring for a client diagnosed with bowel and bladder incontinence. Which is a priority collaborative problem for this client? Indequate nutrition Impaired skin integrity Altered level of consciousness Decreased fluid volume

✅Impaired skin integrity A priority collaborative problem for a client diagnosed with bowel and bladder incontinence is risk for tissue damage and impaired skin integrity. Stool and urine can cause skin irritation, fungal infection, and/or skin breakdown, which are very uncomfortable. Loss of bladder and bowel control can also lead to depression and anxiety. There is no indication that imbalanced nutrition is a problem for this client. Decreased fluid volume and altered level of consciousness are not issues indicated in this client scenario. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

Which nursing action reflects the QSEN competency of Patient-Centered Care? (Select all that apply.) Select all that apply. Designing nursing care with a focus on keeping the client safe Participating on a committee that is evaluating the newest bar-code scanner Including the client in discussions about dietary choices Respecting the client's preference about treatment options Referring to a nursing journal to consider trends in care Using data collected over the past quarter to determine if and how nursing care should change

✅Including the client in discussions about dietary choices ✅Respecting the client's preference about treatment options The QSEN competency of Patient-Centered Care recognizes that the client, with his or her own autonomy, is at the center of all decision making related to care. Respecting the client's preferences about treatment, and including the client in discussions about dietary choices, reflects patient-centered care. Designing nursing care with a focus on safety reflects the QSEN competency of Safety. Referring to a nursing journal to consider trends in care reflects the QSEN competency of Evidence-Based Practice. Participating on a committee that is evaluating the newest bar-code scanner reflects the QSEN competencies of Evidence-Based Practice and Teamwork and Collaboration. Using data collected over the past quarter to determine if and how nursing care should change reflects the QSEN competency of Quality Improvement. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

The nurse is caring for a client at end of life. What is the nurse's priority for the client's care? Promote coping. Increase comfort. Ensure adequate nutrition. Maintain breathing.

✅Increase comfort. The client at the end of life is dying. The most important intervention for the nurse and interprofessional health care team is to ensure that the client is comfortable. The client will most likely eventually not eat or drink and will have breathing problems as death becomes more near. Coping is important but is not the priority. Chapter 03 - Overview of Health Concepts for Medical-Surgical Nursing

At a follow-up homecare visit after repair of a fractured radial bone, an older adult client states, "I am not sleeping at all during the night." The client's partner reports that the client is sleeping all day. Which intervention does the nurse suggest? Taking additional pain medication during the day Increasing the client's daytime activities Placing a "Do not disturb" sign on the door at night Taking herbal remedies to enhance sleep

✅Increasing the client's daytime activities Older adult clients should try to stay awake during the day to prevent insomnia at night. Increasing activities will facilitate this goal. The client did not report interruptions, but insomnia; placing a "Do not disturb" sign on the door, although it may be effective in increasing "sleep time," does not address the client's problem. Pain medication is best taken at night because it causes drowsiness. Encouraging herbal remedies to try to promote sleep is not an appropriate suggestion for the nurse to make. Chapter 04 - Common Health Problems of Older Adults Concepts for Medical-Surgical Nursing

A client with right-sided hemiplegia is in a rehabilitation unit. Which nursing intervention is effective in promoting the client's independence? Assisting the client with all of his or her activities of daily living (ADLs) Sending the client to a long-term care facility Telling the client to do the "best" that he or she can do Instructing the client step-by-step on how to put on his or her robe

✅Instructing the client step-by-step on how to put on his or her robe Instructing the client (step-by-step) on how to put on a garment provides direct teaching of skills. This promotes independence for the client. Assisting the client with all ADLs will not support the client's independence. Telling the client to do her or his best does not help teach new skills and may even add to the client's frustration. Sending the client to a long-term care facility will not support the client in gaining independence.

A postoperative client is vomiting and states, "I am having a lot of pain—a 7 on a scale of 0-10." Which route of administration will the nurse choose to administer an analgesic to the client? Oral Rectal Intravenous Transdermal

✅Intravenous The intravenous route is the best choice for fast relief of nausea and pain. Oral pain medication may exacerbate the client's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes Chapter 05 - Assessment and Concepts of Care for Patients With Pain Concepts for Medical-Surgical Nursing

The nurse is teaching a class on safe patient handling and mobility. What will the nurse include? (Select all that apply.) Select all that apply. Place the bed at hip level when providing direct care. Attempt to lift with a team prior to using client-handling equipment. Keep the client directly in front of your body while providing care. Maintain a wide, stable base with your feet prior to lifting. Place the client 1 foot away from your body prior to lifting.

✅Keep the client directly in front of your body while providing care. ✅Maintain a wide, stable base with your feet prior to lifting. When teaching about safe patient handling, maintain a wide, stable base with your feet prior to lifting and keep the client 1 foot away from your body prior to lifting. The bed should be placed at waist level when providing direct care. The client should be as close to your body as possible when providing care to prevent reaching. If safe patient-handling equipment is available, always use

2.A nurse who is newly hired to manage a busy pediatric office is encouraged to use a transactional leadership style when dealing with subordinates. Which activities best exemplify the use of this type of leadership? Select all that apply. A. The manager institutes a reward program for employees who meet goals and work deadlines. B. The manager encourages the other nurses to participate in health care reform by joining nursing organizations. C. The manager promotes compliance by reminding subordinates that they have a good salary and working conditions. D. The manager makes sure all the employees are kept abreast of new developments in pediatric nursing. E. The manager works with subordinates to accomplish all the nursing tasks and goals for the day. F. The manager allows the other nurses to set their own schedules and perform nursing care as they see fit.

✅a, c. Instituting a reward program and reminding workers that they have a good salary and working conditions are examples of transactional leadership, which is based on a task-and-reward orientation. Team members agree to a satisfactory salary and working conditions in exchange for commitment and compliance to their leader. Encouraging nurses to participate in health care reform is an example of a transformational leadership style. Ensuring that employees keep abreast of new developments in nursing care is a characteristic of quantum leadership. The group and leader work together to accomplish mutually set goals and outcomes with the democratic leadership style, and the laissez-faire style encourages independent activity by group members, such as setting their own schedules and work activities CHAPTER 10 Leading, Managing, and Delegating

9. During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. A. Group decision making B. Group leadership C. Group power D. Group identity E. Group patterns of interaction F. Group cohesiveness

✅a, d, e, f. Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes CHAPTER 8 Communication

4.A nurse is a servant leader working in an economically depressed community to set up a free mobile health clinic for the residents. Which actions by the leader BEST exemplify a key practice of servant leaders? Select all that apply A. The nurse motivates coworkers to solicit funding to set up the clinic. B. The nurse sets only realistic goals that are present oriented and easily achieved. C. The nurse forms an autocratic governing body to keep the project on track. D. The nurse spends time with supporters to help them grow in their roles. E. The nurse first ensures that other's lowest priority needs are served. F. The nurse prizes leadership because of the need to serve others.

✅a, d, f. In order to serve as servant leaders, nurses need to invest in those who support the organization's values, show passion, can play to their strengths, and demonstrate a positive attitude. They should develop their vision to see the future related to a current anticipated need, and motivate others to follow and engage. They also need to provide ongoing opportunities for collaborations, sharing, reflection, encouragement, and celebration, as well as hard work. The servant leader allows others to have a voice, to exercise control, and to practice leading themselves. The servant first makes sure that other people's highest priority needs are being served. The best test, and most difficult to administer, is: Do those served grow as people? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? CHAPTER 10 Leading, Managing, and Delegating

10. A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? A. Pain B. Anxiety C. Depression D. Fluid volume deficit

✅a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior. CHAPTER 8 Communication

9.A nurse is using time management techniques when planning activities for patients. Which nursing action reflects effective time management? A. The nurse asks patients to prioritize what they want to accomplish each day B. The nurse includes a "nice to do" for every "need to do" task on the list C. The nurse "front loads" the schedule with "must do" priorities D. The nurse avoids helping other nurses if scheduling does not permit it

✅a. By asking the patient to prioritize what they want to accomplish each day, the nurse is demonstrating an effective time management technique. In order to manage time, the nurse should establish goals and priorities for each day, differentiating "need to do" from "nice to do" tasks; the nurse should include the patient in this process. The nurse should also establish a time line, allocating priorities to hours in the workday in order to keep track of falling behind and correct the problem before the day is lost. The nurse should use teamwork appropriately to enhance the schedule. b. Magnet hospitals u CHAPTER 10 Leading, Managing, and Delegating

10. A nurse is practicing community-based nursing in a mobile health clinic. What typically is the central focus of this type of nursing care? A. Individual and family health care needs B. Populations within the community C. Local health care facilities D. Families in crisis

✅a. In contrast to community health nursing, which focuses on populations within a community, community-based nursing is centered on individual and family health care needs. Community-based nurses may help families in crisis and work in health care facilities, but these are not the focus of community-based nursing. CHAPTER 4 Health of the Individual, Family, and Community

3. Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients are considered vulnerable populations? Select all that apply. A. A White male diagnosed with HIV B. An African American teenager who is 6 months pregnant C. A Hispanic male who has type II diabetes D. A low-income family living in rural America E. A middle-class teacher living in a large city F. A White baby who was born with cerebral palsy

✅b, c, d, f. National trends in the prevention of health disparities are focused on vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs. CHAPTER 3 Health, Wellness, and Health Disparities

1.A charge nurse in a busy hospital manages a skilled nursing unit using an autocratic style of leadership. Which leadership tasks BEST represent this style of leadership? Select all that apply. A. The charge nurse polls the other nurses for input on nursing protocols. B. The charge nurse dictates break schedules for the other nurses. C. The charge nurse schedules a mandatory in-service training on new equipment. D. The charge nurse allows the other nurses to divide up nursing tasks. E. The charge nurse delegates nursing responsibilities to the staff. F. The charge nurse encourages the nurses to work independently.

✅b, c, e. Autocratic leadership involves the leader assuming control over the decisions and activities of the group, such as dictating schedules and work responsibilities, and scheduling mandatory in-service training. Polling other nurses is an example of democratic leadership, which is characterized by a sense of equality among the leader and other participants, with decisions and activities being shared. In laissez-faire leadership, the leader relinquishes power to the group and encourages independent activity by group members. Examples of laissez-faire leadership style are allowing the nurses to divide up the tasks and encouraging them to work independently. CHAPTER 10 Leading, Managing, and Delegating

5.A nurse manager is attempting to update a health care provider's office from paper to electronic health records (EHR) by using the eight-step process for planned change. Place the following actions in the order in which they should be initiated: A. The nurse devises a plan to switch to EHR. B. The nurse records the time spent on written records versus EHR. C. The nurse attains approval from management for new computers. D. The nurse analyzes all options for converting to EHR. E. The nurse installs new computers and provides an in-service for the staff. F. The nurse explores possible barriers to changing to EHR. G. The nurse follows up with the staff to check compliance with the new system. H. The nurse evaluates the effects of changing to EHR

✅b, f, d, c, a, e, h, g. Planned change involves the following steps: (1) recognize symptoms that indicate a change is needed and collect data, (2) identify a problem to be solved through change, (3) determine and analyze alternative solutions, (4) select a course of action from possible solutions, (5) plan for making the change, (6) implement the change, (7) evaluate the change, and (8) stabilize the change. CHAPTER 10 Leading, Managing, and Delegating

10.A nurse forms a contractual agreement with a morbidly obese patient to achieve optimal weight goals. Which statement best describes the nature of this agreement? "This agreement forms a legal bond between the two of us to achieve your weight goals." "This agreement will motivate the two of us to do what is necessary to meet your weight goals." "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." "This agreement will limit the scope of the teaching session and make stated weight goals more attainable."

✅b. A contractual agreement is a pact two people make, setting out mutually agreed-on goals. Contracts are usually informal and not legally binding. When teaching a patient, such an agreement can help motivate both the patient and the teacher to do what is necessary to meet the patient's learning outcomes. The agreement notes the responsibilities of both the teacher and the learner, emphasizing the importance of the mutual commitment CHAPTER 9 Teaching and Counseling

3. The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow's basic human needs is being met by this nurse? A. Physiologic B. Safety and security C. Self-esteem D. Love and belonging

✅b. By carrying out careful hand hygiene and using sterile technique, nurses provide safety from infection. An example of a physiologic need is clearing a patient's airway. Self-esteem needs may be met by allowing an older adult to talk about a past career. An example of helping meet a love and belonging need is contacting a hospitalized patient's family to arrange a visit. CHAPTER 4 Health of the Individual, Family, and Community

6.A nurse manager who is attempting to institute the SBAR process to communicate with health care providers and transfer patient information to other nurses is meeting staff resistance to the change. Which action would be most effective in approaching this resistance? A. Containing the anxiety in a small group and moving forward with the initiative B. Explaining the change and listing the advantages to the person and the organization C. Reprimanding those who oppose the new initiative and praising those who willingly accept the change D. Introducing the change quickly and involving the staff in the implementation of the change

✅b. Change is ubiquitous, as is resistance to change. The manager should explain the proposed change to all affected, list the advantages of the proposed change for all parties, introduce the change gradually, and involve everyone affected by the change in the design and implementation of the process. The manager should not use the reward/punishment style to overcome resistance to change. CHAPTER 10 Leading, Managing, and Delegating

8. A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? A. "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." B. "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" C. "I will need to call in on the 8th of August because I have a doctor's appointment." D. "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

✅b. Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time CHAPTER 8 Communication

9. A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient's doctor threatens the nurse with firing if the nurse raises questions about the patient's care or calls the consult. What ethical conflict is this nurse experiencing? A. Ethical uncertainty B. Ethical distress C. Ethical dilemma D. Ethical residue

✅b. Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, the nurse fears the loss of job). Ethical uncertainty results from feeling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action. Ethical residue is what nurses experience when they seriously compromise themselves or allow themselves to be compromised. CHAPTER 6 Values, Ethics, and Advocacy

7. The nurse caring for families in a free health care clinic identifies psychosocial risk factors for altered family health. Which example describes one of these risk factors? A. The family does not have dental care insurance or resources to pay for it. B. Both parents work and leave a 12-year-old child to care for his younger brother. C. Both parents and their children are considerably overweight. D. The youngest member of the family has cerebral palsy and needs assistance from community services.

✅b. Inadequate childcare resources is a psychosocial risk factor. Not having access to dental care and obese family members are lifestyle risk factors. Having a family member with birth defects is a biologic risk factor. CHAPTER 4 Health of the Individual, Family, and Community

10.A new nurse manager at a small hospital is interested in achieving Magnet status. Which action would help the hospital to achieve this goal? A. Centralizing the decision-making process B. Promoting self-governance at the unit level C. Deterring professional autonomy to promote teamwork D. Promoting evidence-based practice over innovative nursing practice

✅b. Magnet hospitals use a decentralized decision-making process, self-governance at the unit level, and respect for and acknowledgment of professional autonomy. In Magnet hospitals, 14 characteristics, the Forces of Magnetism, have been recognized that identify quality patient care, excellent nursing care, and innovations in professional nursing practice. CHAPTER 10 Leading, Managing, and Delegating

1. A nurse uses Maslow's hierarchy of basic human needs to direct care for patients on an intensive care unit. For which nursing activities is this approach most useful? A. Making accurate nursing diagnoses B. Establishing priorities of care C. Communicating concerns more concisely D. Integrating science into nursing care

✅b. Maslow's hierarchy of basic human needs is useful for establishing priorities of care. CHAPTER 4 Health of the Individual, Family, and Community

1. A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? Promoting health Preventing illness Restoring health Facilitating coping

✅b. Teaching first aid is a function of the goal to prevent illness. Promoting health involves helping patients to value health and develop specific health practices that promote wellness. Restoring health occurs once a patient is ill, and teaching focuses on developing self-care practices that promote recovery. When facilitating coping, nurses help patients come to terms with whatever lifestyle modification is needed for their recovery or to enable them to cope with permanent health alterations. CHAPTER 9 Teaching and Counseling

6.A nurse has taught a patient with diabetes how to administer his daily insulin. How should the nurse evaluate the teaching-learning process? By determining the patient's motivation to learn By deciding if the learning outcomes have been achieved By allowing the patient to practice the skill he has just learned By documenting the teaching session in the patient's medical record

✅b. The nurse cannot assume that the patient has actually learned the content unless there is some type of proof of learning. The key to evaluation is meeting the learner outcomes stated in the teaching plan. CHAPTER 9 Teaching and Counseling

11.A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? A. "Would you prefer a bath or a shower?" B. "May I help you with a bed bath now or later this morning?" C. "I will be giving you your bath. Do you use soap or shower gel?" D. "I prefer a shower in the evening. When would you like your bath?"

✅b. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones. CHAPTER 8 Communication

4. A nurse caring for patients in a long-term care facility uses available resources to help patients achieve Maslow's highest level of needs: self-actualization needs. Which statements accurately describe these needs? Select all that apply. A. Humans are born with a fully developed sense of self-actualization. B. Self-actualization needs are met by depending on others for help. C. The self-actualization process continues throughout life. D. Loneliness and isolation occur when self-actualization needs are unmet. E. A person achieves self-actualization by focusing on problems outside self. F. Self-actualization needs may be met by creatively solving problems.a

✅c, e, f. Self-actualization, or reaching one's full potential, is a process that continues throughout life. A person achieves self-actualization by focusing on problems outside oneself and using creativity as a guideline for solving problems and pursuing interests. Humans are not born with a fully developed sense of self-actualization, and self-actualization needs are not met specifically by depending on others for help. Loneliness and isolation are not always the result of unmet self-actualization needs CHAPTER 4 Health of the Individual, Family, and Community

Question 7 of 15 Which nursing element reflects systems thinking at the global level of practice? A.Facility health policy B. Quality improvement initiative C. Determinants of health D. Interprofessional practice

✅c. Determinants of health Systems thinking can exist globally, nationally, or locally. An example of global level systems thinking is the determinants of health as these are elements of health that are developed on a global level in relation to population health. Chapter 02 - Clinical Judgment and Systems Thinking Concepts for Medical-Surgical Nursing

9. A visiting nurse working in a new community performs a community assessment. What assessment finding is indicative of a healthy community? A. It meets all the needs of its inhabitants B. It has mixed residential and industrial areas C. It offers access to health care services D. It consists of modern housing and condominiums

✅c. A healthy community offers access to health care services to treat illness and to promote health. A healthy community does not usually meet all the needs of its residents, but should be able to help with health issues such as nutrition, education, recreation, safety, and zoning regulations to separate residential sections from industrial ones. The age of housing is irrelevant as long as residences are maintained properly according to code. CHAPTER 4 Health of the Individual, Family, and Community

7. A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? A. Determining the established goals of the institution B. Ensuring that verbal and nonverbal communication is congruent C. Engaging in self-talk to plan the day and decrease fear D. Speaking with fellow colleagues about how they feel

✅c. By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety. CHAPTER 8 Communication

8.An RN on a surgical unit is behind schedule administering medications. Which of the RN's other tasks can be safely delegated to a UAP? A. The assessment of a patient who has just arrived on the unit B. Teaching a patient with newly diagnosed diabetes about foot care C. Documentation of a patient's I & O on the flow chart D. Helping a patient who has recently undergone surgery out of bed for the first time

✅c. Documenting a patient's I & O on a flow chart may be delegated to a UAP. Professional nurses are responsible for the initial patient assessment, discharge planning, health education, care planning, triage, interpretation of patient data, care of invasive lines, administering parenteral medications. What they can delegate are assistance with basic care activities (bathing, grooming, ambulation, feeding) and things like taking vital signs, measuring intake and output, weighing, simple dressing changes, transfers, and post mortem care. CHAPTER 10 Leading, Managing, and Delegating

3. A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? Ask Me 3 Newest Vital Sign (NVS) Teach-back method TEACH acronym

✅c. The teach-back tool is a method of assessing literacy and confirming that the learner understands health information received from a health professional. The Ask Me 3 is a brief tool intended to promote understanding and improve communication between patients and their providers. The NVS is a reliable screening tool to assess low health literacy, developed to improve communications between patients and providers. The TEACH acronym is used to maximize the effectiveness of patient teaching by tuning into the patient, editing patient information, acting on every teaching moment, clarifying often, and honoring the patient as a partner in the process. CHAPTER 9 Teaching and Counseling

1. A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply. A. The United States has become less inclusive of same-sex couples. B. Cultural diversity is limited to people of varying cultures and races. C. Cultural diversity is separate and distinct from health and illness. D. People may be members of multiple cultural groups at one time. E. Culture guides what is acceptable behavior for people in a specific group. F. Cultural practices may evolve over time but mainly remain constant.

✅d, e, f. A person may be a member of multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. The United States has become more (not less) inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, including culture, ethnicity, and race, is an integral component of both health and illness. CHAPTER 5 Cultural Diversity

5. A nurse works with families in crisis at a community mental health care facility. What is the BEST broad definition of a family? A. A father, a mother, and children B. A group whose members are biologically related C. A unit that includes aunts, uncles, and cousins D. A group of people who live together and depend on each other for support

✅d. Although all the responses may be true, the best definition is a group of people who live together and depend on each other for physical, emotional, or financial support CHAPTER 4 Health of the Individual, Family, and Community

7.A nurse is asked to act as a mentor to a new nurse. Which nursing action is related to this process? A. The nurse mentor accepts payment to introduce the new nurse to his or her responsibilities B. The nurse mentor hires the new nurse and assigns duties related to the position C. The nurse mentor makes it possible for the new nurse to participate in professional organizations D. The nurse mentor advises and assists the new nurse to adjust to the work environment of a busy emergency department

✅d. Mentorship is a relationship in which an experienced person (the mentor) advises and assists a less experienced person (protégé). This is an effective way of easing a new nurse into leadership responsibilities. An experienced nurse who is paid to introduce an employee to new responsibilities through teaching and guidance describes a preceptor, not a mentor. The nurse mentor does not hire or schedule new nurses. Nurses do not need mentors to join professional organizations. CHAPTER 10 Leading, Managing, and Delegating

1. During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? "You need to speak to the patient quietly so you don't disturb the other patients." "Let me help you with your transfer technique." "When you are finished, be sure to apologize for your rough demeanor." "When your patient is safe and comfortable, meet me at the desk."

✅d. The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication. CHAPTER 8 Communication

3.A nurse manager of a busy cardiac unit observes disagreements between the RNs and the LPNs related to schedules and nursing responsibilities. At a staff meeting, the manager compliments all the nurses on a job well done and points out that expected goals and outcomes for the month have been met. The nurse concludes the meeting without addressing the disagreements between the two groups of nurses. Which conflict resolution strategy is being employed by this manager? A. Collaborating B. Competing C. Compromising D. Smoothing

✅d. The manager who resolves conflict by complimenting the parties involved and focusing on agreement rather than disagreement is using smoothing to reduce the emotion in the conflict. The original conflict is rarely resolved with this technique. Collaborating is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. Competing results in a win for one party at the expense of the other group. Compromising occurs when both parties relinquish something of equal value. CHAPTER 10 Leading, Managing, and Delegating

A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed ciprofloxacin (Cipro) 250 mg PO two times daily. The amount available is 100 mg/tablet. How many tablets should the nurse administer with each dose? tablets

✅x = 2.5 tablets In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the number of tablets the nurse should administer. This item requires critical thinking because you have to analyze the provided facts to determine the dosage, select a formula, enter data into the formula, and then perform the needed calculations. STEP 1: What is the dose needed? Dose needed = Desired; 250 mg STEP 2: What is the dose available? Dose available = Have; 100 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg) STEP 4: What is the quantity of the dose available? 1 tablet STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 250 mg x 1 tablet / 100 mg = x tablets; 250 x 1 / 100 = 2.5; x = 2.5 tablets. NurseLogic Knowledge and Clinical Judgment Beginner

A nurse is providing discharge education to the parents of a preschooler who is prescribed acetaminophen (Tylenol) 300 mg every 4 hr as needed. The acetaminophen liquid suspension that has been prescribed provides 120 mg/5 mL. How many teaspoons should the nurse teach the parents to administer per dose? tsp

✅x = 2.5 tsp. In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the number of teaspoons the nurse should teach the parents to administer. This item requires critical thinking because you have to analyze the provided information to determine the dosage, select the formula, enter data into the formula, and then perform the needed calculations. STEP 1: What is the dose needed? Dose needed = Desired; 300 mg STEP 2: What is the dose available? Dose available = Have; 120 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg). STEP 4: What is the quantity of the dose available? 5 mL STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 300 mg x 5 mL / 120 mg = x mL; x = 12.5 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 12.5 mL / x; 5x = 12.5; x = 2.5 tsp.

Teaching Strategies for the Three Learning Domains

❑Cognitive Domain Lecture or discussion Panel discussion Discovery Audiovisual materials Printed materials Programmed instruction Computer-assisted instruction programs ❑Affective Domain Role modeling Discussion Panel discussion Audiovisual materials Role playing Printed materials ❑Psychomotor Domain Demonstration Discovery Audiovisual materials Printed materials CHAPTER 9 Teaching and Counseling

3. The client with a head injury is ordered a CT scan of the head with contrast dye. Which intervention should the nurse include when discussing this procedure? 1. Instruct the client to not take any of the routine medications. 2. Inform the client an intravenous line will be started prior to the procedure. 3. Ask about any allergies to nonsteroidal anti-inflammatory medication. 4. Explain that the client will be given sedatives prior to the procedure.

1. Antihypertensive medications do not inter- fere with the contrast dye that is used when performing a CT scan. Glucophage may be held prior to or following the procedure until a normal creatinine level can be established. ✅2. The client will have an intravenous line to administer the contrast dye. 3. The contrast dye is iodine based so an allergy to shellfish would be important, but there is no contraindication to taking an NSAID. 4. Sedatives are not administered for this procedure; however, if the client is anxious about the machine, sometimes an antianxi- ety medication is Comprehensive Examination. Pharmacology Success

68. The client admitted to the medical floor for pneumonia informs the nurse of taking an aspirin every day. Which intervention should the nurse implement? 1. Assess the client's blood pressure and pulse. 2. Check the client's urine for ketones. 3. Monitor for an elevated temperature. 4. Document the information in the chart.

1. Aspirin does not affect the blood pressure and pulse; therefore, the nurse would not need to implement this intervention. 2. Aspirin will not cause a breakdown of fat, which results in increased ketone production. 3. Daily aspirin is taken as an antiplatelet medication, not as an antipyretic. ✅4. This information should be docu- mented in the chart, and no further action should be taken.

2. The nurse is administering 0900 medications to the following clients. Which client should the nurse question administering the medication? 1. The client receiving a calcium channel blocker who drank a full glass of water. 2. The client receiving a beta blocker who has a blood pressure of 96/70. 3. The client receiving a nitroglycerin patch who is complaining of a headache. 4. The client receiving an antiplatelet medication who has a platelet count of 33,000

1.The client receiving a calcium channel blocker (CCB) can take the medication with water; therefore, the nurse would not question administering this medication. 2. This blood pressure is above 90/60; there- fore, the nurse would not question adminis- tering this medication. 3. Headache is a side effect of nitroglycerin; therefore, the nurse would not question administering this medication but could administer Tylenol or a nonnarcotic analgesic. ✅4. The client's platelet count is not moni- tored when administering antiplatelet medication, but if the nurse is aware that the client has a low platelet count the nurse would question administering any medication that would inactivate the platelets. Comprehensive Examination. Pharmacology Success

A client has just received a bisacodyl suppository. How soon after administration does the nurse expect results to be evident? 5 to 10 minutes 10 to 15 minutes 15 to 30 minutes 30 to 45 minutes

15 to 30 minutes The nurse expects results to be evident within 15 to 30 minutes. Bisacodyl suppository agents are often used in bowel training programs. Suppositories must be placed against the bowel wall to stimulate the sacral arc and promote rectal emptying, which occurs within 15 to 30 minutes after administration. Five to fifteen minutes is not enough time for a glycerin suppository to be effective; the mechanism of action requires a longer time period. Action from the suppository should occur by 30 minutes after insertion.

Answer: B, D Rationale: The nurse is supporting the client emotionally while he or she tells the family the information learned from the genetic/genomic testing results. He or she is also ascertaining the client's understanding of the testing results by hearing the explanation in the client's own words. If there are erroneous statements made, the nurse can reinforce the interpretation made by the genetics professional. The nurse is neither interpreting the results nor counseling the client or family about what steps to take next. This situation does not require an advocate role. Cognitive Level: Applying or higher Client needs category: Psychosocial Integrity Nursing Process Step: Intervention

Chapter 06 - Concepts of Genetics and Genomics for Medical-Surgical Nursing

12 of 15 The nurse is caring for a client with a knife wound. How will the nurse document this type of injury? Penetrating Blunt Acceleration-deceleration Blast

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

9 of 15 Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and has a grossly deformed left leg with no pulse. What is the first resuscitation intervention to be performed? Perform artificial respirations. Apply a cervical collar to the neck. Realign the leg and recheck for pulse. Clear the airway of secretions.

Chapter 10 - Concepts of Emergency and Trauma Nursing Medical-Surgical Nursing

98. The client diagnosed with chronic pancreatitis is prescribed the pancreatic enzyme Pancrease. Which data indicates the medication is effective? 1. No bowel movement for 3 days. 2. Fatty, frothy, foul-smelling stools. 3. Brown, soft, formed stools. 4. Normal bowel sounds in four quadrants.

Constipation does not determine the effectiveness of the medication. Steatorrhea (fatty, frothy, foul-smelling stools) or diarrhea indicates a lack of pan- creatic enzymes in the small intestines. This would indicate the dosage is too small and needs to be increased. ✅3. Normal bowel movements indicate the medication is effective in prevent- ing steatorrhea. Normal bowel sounds would not indicate the medication is effective. Comprehensive Examination. Pharmacology Success

Common Teaching Mistakes

Ignoring the restrictions of the patient's environment Failing to accept that patients have the right to change their mind Using medical jargon Failing to negotiate goals Duplicating teaching that other team members have done Overloading the patient with information Choosing the wrong time for teaching Not evaluating what the patient has learned Not reviewing educational media, or relying exclusively on media Failing to document patient teaching and plan for follow-up or teaching reinforcement

94. The client who is obese is prescribed sibutramine (Meridia), a selective serotonin re- uptake inhibitor, therapy to aid in weight reduction. Which information should the nurse teach the client? 1. While taking the medications the client does not need to limit the caloric intake. 2. The medications cannot be taken with antihypertensive medications. 3. Report a sustained increase of heart rate and blood pressure immediately. 4. The client will be taking the medications for 2 or 3 weeks at a time.

Medications alone will not guarantee weight loss. The client should exercise regularly and limit calories to lose an appreciable amount of weight. Some of the medications have drug inter- actions with selective serotonin reuptake inhibitors, MAO inhibitors, triptans, and some opioids but not with antihyperten- sive medications. ✅3. These symptoms indicate serotonin syndrome and can be life threatening. The nurse should teach the client to monitor the pulse and blood pressure and report significant changes. The medications are prescribed for up to a year at a time Comprehensive Examination. Pharmacology Success

Planned Change: An Eight-Step Process

Planned change is a purposeful, systematic effort to alter or bring about change through the intervention of a change agent. The same steps apply whether dealing with individuals or groups. Recognize symptoms that indicate a change is needed and collect data. • ❑ ❑Identify a problem to be solved through change. Analyze the symptoms and reach a conclusion. Note resistance or barriers to change and factors that promote the desired change. ❑Determine and analyze alternative solutions to the problem. Consider the advantages, disadvantages, and consequences of each alternative. An analysis of various proposed solutions to a problem may result in using a combination of alternatives. ❑Select a course of action from possible alternatives. Avoid initiating too many courses of action and thereby dissipating resources and energy. ❑Plan for making the change. This step is crucial to effect change successfully. Start by stating specific objectives, designing a plan for change, developing timetables, selecting people to assist with making the change, and anticipating how to stabilize change and deal with resistance to change. Unless a plan is clearly designed, effecting change is likely to be a chaotic experience. ❑Implement the selected course of action to effect change. Put the plan for change into effect. During this period, flexibility is important to adapt to unforeseen problems. Evaluate the effects of change by comparing them with objectives stated in the plan for change. Adjustments can be made in the plan as necessary after evaluation. If the results of evaluation indicate that the course of action selected to solve a problem has been unsuccessful, an adjustment should be made or another course of action selected. Stabilize the change. When a solution has been found, take measures to make the change permanent. Continue follow-up until the change is firmly established. CHAPTER 10 Leading, Managing, and Delegating

A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? Spongy gums that are receding Fissures at eyelid corners Easily plucked hair Deep reddish-colored tongue

Spongy gums that are receding In this item, you need nursing knowledge of clinical findings that are associated with healthy nutrition. Based on an understanding of this information, you can identify which option describes an expected finding in clients who are properly nourished. This item requires foundational thinking because you only need to recall knowledge related to expected clinical findings. Spongy gums that are receding is not suggestive of a healthy nutritional status. Gums should be pink to red in color, without swelling, bleeding, or receding from the gum line. Fissures at eyelid corners In this item, you need nursing knowledge of clinical findings that are associated with healthy nutrition. Based on an understanding of this information, you can identify which option describes an expected finding in clients who are properly nourished. This item requires foundational thinking because you only need to recall knowledge related to expected clinical findings. A fissure at the eyelid corner is not suggestive of a healthy nutritional status. The eyes should be clear and shiny, without sores or fissures at the corner of membranes or eyelids. Easily plucked hair In this item, you need nursing knowledge of clinical findings that are associated with healthy nutrition. Based on an understanding of this information, you can identify which option describes an expected finding in clients who are properly nourished. This item requires foundational thinking because you only need to recall knowledge related to expected clinical findings. Easily plucked hair is not suggestive of a healthy nutritional status. Hair should be shiny and firm, unable to be easily plucked. ✅Deep reddish-colored tongue In this item, you need nursing knowledge of clinical findings that are associated with healthy nutrition. Based on an understanding of this information, you can identify which option describes an expected finding in clients who are properly nourished. This item requires foundational thinking because you only need to recall knowledge related to expected clinical findings. Deep reddish-colored tongue is suggestive of a healthy nutritional status. The tongue should be a healthy pink to a deep, reddish color with surface papillae present, without swelling or lesions. NurseLogic Knowledge and Clinical Judgment Beginner

70. Which statement best explains the scientific rationale for a client taking antioxidants? 1. Antioxidants will increase the availability of oxygen to the heart muscle. 2. Antioxidants will help prevent platelet aggregation in the arteries. 3. Antioxidants decrease the buildup of atherosclerotic plaque in the arteries. 4. Antioxidants decrease the oxygen demands of the peripheral tissues.

This is the scientific rationale of a coro- nary vasodilator. This is the scientific rationale for an- tiplatelet medications. ✅3. Antioxidants are being prescribed to help prevent cardiovascular diseases. Rest is the only action that will help de- crease the oxygen demands of the periph- eral tissues. Comprehensive Examination. Pharmacology Success

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication? Weight loss WBC 2,800/mm3 Heart rate 64/min Insomnia

Weight loss In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Weight loss does not indicate the client is experiencing an adverse effect of the medication. Instead, weight gain is an adverse effect that can occur in clients who are taking clozapine because of the blockage of H1 histamine receptors. ✅WBC 2,800/mm3 In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Clozapine is a second-generation antipsychotic used to relieve symptoms of schizophrenia and to reduce suicidal behaviors in clients who have schizophrenia or schizoaffective disorder. Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis, which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal. Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3 indicates the client is experiencing an adverse effect of the medication. Heart rate 64/min In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. A heart rate of 64/min does not indicate the client is experiencing an adverse effect of the medication. Instead, tachycardia is an adverse effect that can occur in clients who are taking clozapine because of the blockage of muscarinic cholinergic receptors. Insomnia In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Insomnia does not indicate the client is experiencing an adverse effect of the medication. Instead, sedation is an adverse effect that can occur in clients who are taking clozapine because of the blockage of H1 histamine receptors. NurseLogic Knowledge and Clinical Judgment Advanced

A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter? Dorsal recumbent Orthopneic Side-lying Supine

✅Supine MY ANSWER To answer this item, you need knowledge of inserting an indwelling urinary catheter on a male client. This item requires foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Indwelling urinary catheters are indicated in numerous situations, such as relief of bladder distension, strict measurement of urinary output, need for bladder irrigations, and surgery. A prescription from the provider is required for urethral catheterization. When preparing to implement this procedure, it is important to ensure client privacy by draping nonessential body parts and positioning the client for optimal visualization while still maintaining comfort. A male client should be positioned in the supine position for insertion of an indwelling urinary catheter. This position allows for optimal visualization, which reduces trauma and increases success of insertion. Dorsal recumbent To answer this item, you need knowledge of inserting an indwelling urinary catheter on a male client. This item requires foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Indwelling urinary catheters are indicated in numerous situations, such as relief of bladder distension, strict measurement of urinary output, need for bladder irrigations, and surgery. A prescription from the provider is required for urethral catheterization. When preparing to implement this procedure, it is important to ensure client privacy by draping nonessential body parts and positioning the client for optimal visualization while still maintaining comfort. A male client should not be positioned in the dorsal recumbent position for insertion of an indwelling urinary catheter. This position is appropriate for females. Orthopneic To answer this item, you need knowledge of inserting an indwelling urinary catheter on a male client. This item requires foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Indwelling urinary catheters are indicated in numerous situations, such as relief of bladder distension, strict measurement of urinary output, need for bladder irrigations, and surgery. A prescription from the provider is required for urethral catheterization. When preparing to implement this procedure, it is important to ensure client privacy by draping nonessential body parts and positioning the client for optimal visualization while still maintaining comfort. A male client should not be positioned in the orthopneic position for insertion of an indwelling urinary catheter. This position improves respiratory effort and is used to increase chest expansion, especially in clients who are having difficulty exhaling. It is not a position used during catheterization. Side-lying To answer this item, you need knowledge of inserting an indwelling urinary catheter on a male client. This item requires foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Indwelling urinary catheters are indicated in numerous situations, such as relief of bladder distension, strict measurement of urinary output, need for bladder irrigations, and surgery. A prescription from the provider is required for urethral catheterization. When preparing to implement this procedure, it is important to ensure client privacy by draping nonessential body parts and positioning the client for optimal visualization while still maintaining comfort. A male client should not be positioned in the side-lying position for insertion of an indwelling urinary catheter. A female client who is unable to abduct the leg at her hip joint should be positioned side-lying with the upper leg flexed at the hip. NurseLogic Knowledge and Clinical Judgment Beginner

Question 7 of 13 What does the nurse recognize is the fastest growing technology being used for informatics? Drug information libraries Medication bar code administration Telehealth and telenursing Electronic health record

✅ Telehealth and telenursing Expanding telehealth (including telenursing) is a goal for Healthy People 2030 and is expanding globally to meet the needs of many clients in a cost-effective manner. Chapter 01 - Overview of Professional Nursing Concepts for Medical-Surgical Nursing

Heart Attack: Know the Symptoms. Take Action

❑Chest Pain or Discomfort Discomfort in the center or left side of the chest that lasts more than a few minutes or goes away and comes back. May feel like pressure, squeezing, fullness, or pain. May also feel like heartburn or indigestion. ❑Other Upper Body Pain or Discomfort May be felt in one or both arms, the back, shoulders, neck, jaw, or upper part of the stomach (above the belly button). ❑Shortness of Breath May be the only symptom, or it may occur before or along with chest pain or discomfort. May occur when resting or during easy activities. ❑Other Possible Symptoms May include breaking out in a cold sweat, feeling unusually tired, nausea, or lightheadedness. Any sudden new symptom or change in usual symptoms also should be a concern. CHAPTER 9 Teaching and Counseling

Culturally Competent Patient Teaching

❑Develop an understanding of the patient's culture. ❑Work with a multicultural team in developing educational programs. ❑Be aware of personal assumptions, biases, and prejudices. ❑Understand the core cultural values of the patient or group. ❑Develop written materials in the patient's preferred language.

Assessment Parameters

❑Knowledge, Skills, and Attitudes Knowledge, skills, and attitudes that are of priority to the patient New knowledge, skills, or attitudes that are necessary for patients and families to learn in order to manage their health care ❑Readiness to Learn Emotional readiness Emotional health Motivation for learning Self-concept and body image Sense of responsibility for self Experiential readiness Social and economic stability Past experiences with learning Attitude toward learning Culture ❑Ability to Learn Physical condition Cognitive ability to learn Acuity of senses Developmental considerations Level of education Literacy Communication skills Preferred language ❑Learning Strengths Successful learning in the past Comprehension, reasoning, memory, or psychomotor skills High motivation Strong network Adequate financing CHAPTER 9 Teaching and Counseling

Summary of Patient Goals for the Three Phases of the Helping Relationship

❑Orientation Phase •The patient will call the nurse by name. •The patient will accurately describe the roles of the •participants in the relationship. •The patient and nurse will establish an agreement about: •Goals of the relationship •Location, frequency, and length of the contacts •Duration of the relationship ❑Working Phase •The patient will actively participate in the relationship. •The patient will cooperate in activities that work toward achieving mutually acceptable goals. •The patient will express feelings and concerns to the nurse. ❑Termination •The patient will participate in identifying the goals accomplished or the progress made toward goals. •The patient will verbalize feelings about the termination of the relationship.

13. When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? A. Cliché B. Giving advice C. Being judgmental D. Changing the subject

✅a. Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition CHAPTER 8 Communication

6. A nurse manager schedules a clinic for the staff to address common nursing interventions used in the facility and to explore how they can be performed more efficiently and effectively. The nurse manager's actions to change clinical practice are an example of a situation described by which nursing theory? A. Prescriptive theory B. Descriptive theory C. Developmental theory D. General systems theory

a. Prescriptive theories address nursing interventions and are designed to control, promote, and change clinical nursing practice. Descriptive theories describe a phenomenon, an event, a situation, or a relationship. Developmental theory outlines the process of growth and development of humans as orderly and predictable, beginning with conception and ending with death. General systems theory describes how to break whole things into parts and then to learn how the parts work together in "systems." CHAPTER 2 Theory, Research, and Evidence-Based Practice

9. A nurse studies the culture of Native Alaskans to determine how their diet affects their overall state of health. Which method of qualitative research is the nurse using? A. Historical B. Ethnography C. Grounded theory D.Phenomenology

b. Ethnographic research was developed by the discipline of anthropology and is used to examine issues of culture of interest to nursing. Historical research examines events of the past to increase understanding of the nursing profession today. The basis of grounded theory methodology is the discovery of how people describe their own reality and how their beliefs are related to their actions in a social scene. The purpose of phenomenology (both a philosophy and a research method) is to describe experiences as they are lived by the subjects being studied. CHAPTER 2 Theory, Research, and Evidence-Based Practice

A nurse working in a rehabilitation facility focuses on the goal of restoring health for patients. Which examples of nursing interventions reflect this goal? Select all that apply. A. A nurse counsels adolescents in a drug rehabilitation program B. A nurse performs range-of-motion exercises for a patient on bedrest C. A nurse shows a diabetic patient how to inject insulin D. A nurse recommends a yoga class for a busy executive E. A nurse provides hospice care for a patient with end-stage cancer F. A nurse teaches a nutrition class at a local high school

a, b, c. Activities to restore health focus on the person with an illness and range from early detection of a disease to rehabilitation and teaching during recovery. These activities include drug counseling, teaching patients how to administer their medications, and performing range-of-motion exercises for bedridden patients. Recommending a yoga class for stress reduction is a goal of preventing illness, and teaching a nutrition class is a goal of promoting health. A hospice care nurse helps to facilitate coping with disability and death. CHAPTER 1 Introduction to Nursing

8. The nurse uses the agent-host-environment model of health and illness to assess diseases in patients. This model is based on what concept? A. Risk factors B. Demographic variables C. Behaviors to promote health D. Stages of illness

✅a. The interaction of the agent, host, and environment creates risk factors that increase the probability of disease. CHAPTER 3 Health, Wellness, and Health Disparities

Foundations of Nursing Practice UNIT I/Nursing ATI questions

Conjuntos de estudio relacionados

Legit: Lock-Out-Tag-Out

Intro to film Chapter 3- Film Fiction and Dramatic Elements

Prep U Chapter 62

holy shit 438

english

jc science chemistry acids bases pH

Chapter 29: Structure and Function of the Cardiovascular System

Math Chapter 4 Vocabulary

Unit 13: Individual Tax Credits

Test 3 - Chapter 9 - Antibody Functions

Econ Ch. 6

Draft

GI medications HESI

Psychology 9-14

Chapter 4 Race Relations

Ch. 3 Review Questions

Mastering A&P - Chapter 9

Chapter 3 Cummulative Quiz

Unit 1: General Information

ISM 4220 CH 9