Fundamental Skill

Which nursing action is most important when caring for a client using medications to manage disease in the hospital? 1. Administering the medications 2. Teaching about the medications 3. Encouraging client adherence to medication regimen 4. Evaluating client ability to self-administer medications

1. Administering the medications The most important part of nursing practice when caring for a client using medications to manage disease in the hospital setting is administering those medications. Administering medications safely requires an understanding of the legal aspects of healthcare, pharmacology, pathophysiology, human anatomy, and mathematics. Teaching about the medications, encouraging adherence to them, and evaluating the client's ability to self-administer them are nursing responsibilities performed before or after medication administration.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? 1. Contact an interpreter provided by the hospital. 2. Contact the client's family member to translate for the client. 3. Communicate with the client using Spanish phrases the nurse learned in a college course. 4. Communicate with the client with the use of a hospital-approved Spanish dictionary.

1. Contact an interpreter provided by the hospital. Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect? 1. Demonstration of a personal bias 2. Problem solving based on assessment 3. Determination of client acuity to set priorities 4. Consideration of the complexity of client care

1. Demonstration of a personal bias When nurses make judgmental remarks and client needs are not placed first, the standards of care are violated and quality of care is compromised. Assessments should be objective, not subjective and biased. There is no information about the client's acuity to come to this conclusion regarding priorities. The statement does not reflect information about complexity of care.

Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply. 1. Fatigue 2. Increased libido 3. Morning sickness 4. Breast enlargement 5. Braxton Hicks contractions

1. Fatigue 3. Morning sickness 4. Breast enlargement Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester of pregnancy. Braxton Hicks contractions are observed during the third trimester of pregnancy.

During follow-up visits, the client's child reports to the nurse, "I tell my parent every day about what may happen if medications aren't taken as prescribed. Despite that, my parent does not take the medication regularly and is depressed." What can be inferred about the client's motivational level? 1. Not motivated 2. Intrinsically motivated 3. Extrinsically motivated with self-determination 4. Extrinsically motivated without self-determination

1. Not motivated If the client is not motivated, then the client may not attempt to eradicate the illness and feel depressed because of the illness. If the client is intrinsically motivated, then the client shows more interest in taking their medications on their own rather than because of pressure from other individuals. The client is motivated extrinsically with or without self-determination when they may take medication regularly when reminded to do so or when pressured by others.

Which action made by the client indicates that they are in the precontemplation stage of Transtheoretical Model of Change? 1. Refuses to think about changing 2. Intends to change in the next 60 days 3. Sustains the changed action for 6 months 4. Recognizes the advantages of the change

1. Refuses to think about changing The Transtheoretical Model of Change model defines changing patterns in an individual in five stages based on beliefs of readiness to change. The phases are precontemplation, contemplation, preparation, action, and maintenance. The client refuses and does not think about the change in the precontemplation stage. The client intends to change in next 60 days in the preparation stage. The client recognizes the beneficial effects of the change and thinks about the change within 6 months in the contemplation stage. In the maintenance stage, the client sustains the changed action for 6 months and follows preventive measures to prevent relapse.

Which assessment finding is associated with depression? 1. The client has islands of intact memory. 2. The client has impaired recent and remote memory. 3. The client has impaired recent and immediate memory. 4. The client needs step-by-step instructions for simple tasks.

1. The client has islands of intact memory. Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? 1. Tubing injection port 2. Distal end of the tubing 3. Urinary drainage bag 4. Catheter insertion site

1. Tubing injection port The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply. 1. Using pincer grasp well 2. Picking up small objects 3. Showing hand preference 4. Crawling on hands and knees 5. Pulling oneself to standing or sitting

1. Using pincer grasp well 2. Picking up small objects 3. Showing hand preference The fine-motor skills evident in 8 to 10 month-old infants include the accurate use of the pincer grasp. It also involves picking up small objects. At this stage, the infants may also demonstrate a hand preference. Crawling on hands and knees and pulling oneself to standing or sitting position are considered gross motor skills.

An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client? 1. Clinical nurse specialist (CNS) 2. Certified nurse midwife (CNM) 3. Certified nurse practitioner (CNP) 4. Certified registered nurse anesthetist (CRNA)

2. Certified nurse midwife (CNM) A certified nurse midwife (CNM) is qualified and has the skills to care for a pregnant woman. A clinical nurse specialist (CNS) is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. A certified nurse practitioner (CNP) is an APRN who provides healthcare to a group of clients, usually in an outpatient, ambulatory care, or community-based setting. A certified registered nurse anesthetist (CRNA) is an APRN with an advanced education in a nurse anesthesia accredited program.

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? 1. Administer the prescribed as needed (PRN) sedative. 2. Encourage the client to express feelings. 3. Explain the postprocedure course of treatment. 4. Reassure the client that there are others with this problem.

2. Encourage the client to express feelings. Communication is important in relieving anxiety and reducing stress. Administering the prescribed PRN sedative does not acknowledge the client's feelings and does not address the source of the anxiety. Learning is limited when anxiety is too high. The focus should be on the client, not others. Reassurance may cut off communication and deny emotions.

Which statement defines the term family resiliency? 1. Family resiliency is the uniqueness of each family. 2. Family resiliency is the ability of the family to cope with stressors. 3. Family resiliency is the intrafamilial system of support and structure. 4. Family resiliency is the ability of the family to transcend.

2. Family resiliency is the ability of the family to cope with stressors. Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults, however, the family is capable of transcending inevitable lifestyle changes.

Which action correlates with the relevance strategy of the motivational learning model proposed by John Keller? 1. Extrinsic and intrinsic reinforcements for any learning effort 2. Linking the person's needs, interests, and motives for learning 3. Arousing and sustaining a person's curiosity and interest in learning 4. Having positive hope for successful achievements as a result of learning

2. Linking the person's needs, interests, and motives for learning John Keller proposed a motivational learning model that includes four factors: attention, relevance, confidence, and satisfaction (ARCS). Relevance strategies involve linking the person's needs, interests, and motives for learning. The attention strategies include arousing and sustaining one's curiosity and interest. Confidence strategies include helping people develop a positive expectation for goal achievement. Satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts.

After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococci (VRE), the nurse should take which step to ensure proper disposal of the soiled dressing? 1. Place the dressing in the bedside trash can. 2. Place the dressing in a red bag/hazardous materials bag. 3. Contact Environmental Services personnel to pick up the dressing. 4. Transport the dressing to the laboratory to be placed in the incinerator.

2. Place the dressing in a red bag/hazardous materials bag. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; thus, the dressing should be placed in a red bag or hazardous materials bag. The soiled dressing should not be placed in a single bag and left in the trash can. Infection control is every healthcare worker's responsibility, not just Environmental Services'. The lab is not responsible for disposal of hazardous wastes that occur as a result of normal nursing activities.

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction? 1. The nurse records the vital signs and leaves the room. 2. The nurse adjusts the bed and asks if the client is comfortable. 3. The nurse leaves the door of the room open while attending to the client. 4. The nurse tells the client that the primary healthcare provider will visit soon.

2. The nurse adjusts the bed and asks if the client is comfortable. The nurse expresses concern and commitment by adjusting the bed and asking if the client is comfortable. This intervention shows the nurse's willingness to enter into a nurse-client relationship and promotes greater client satisfaction. The client may feel that the nurse is just performing a set of assigned tasks by recording the vital signs and leaving the room. This intervention does not build client satisfaction. The nurse should close the door after entering the room to ensure privacy while providing care. The nurse does not provide effective client satisfaction by informing the client about the primary healthcare provider's imminent visit.

What is the role of a case manager in a healthcare organization? 1. To delegate work on the unit suitably 2. To follow up with the client after discharge 3. To provide direct care for the client at the bedside 4. To unite the strategic direction of the organization

2. To follow up with the client after discharge A case manager is an advanced practice nurse who coordinates a client's acute care in the hospital and follows up with the client after discharge. A nurse manager delegates work appropriately to the nursing staff on the unit. A registered nurse provides direct care to the client at the bedside. The nurse executive is often the vice president or strategic director of nursing in a healthcare organization.

A client with chronic renal failure stops responding to the treatment. On examination, the primary healthcare provider determines that the client is terminally ill. What is the best nursing intervention in this situation? 1. Suggest that the family members get a second opinion. 2. Suggest that the family members continue to try different treatments. 3. Encourage the family members to provide pallative care to the client. 4. Inform the family members that the disease is no longer curable and the client will die shortly.

3. Encourage the family members to provide pallative care to the client. Clients who are terminally ill and no longer respond to treatment are in need of palliative care. Palliative care promotes client comfort and provides important interventions to support the client and family at the end of life. There is no need to get a second opinion from another primary healthcare provider, because the client is terminally ill. Continuing to attempt different treatment until of the death of the client may cause more client suffering. It is not advisable to inform the family members that the client will die soon because it may lead to emotional stress. The palliative care team will help prepare the family for the client's death.

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer? 1. It shows empathy. 2. It uses distraction. 3. It gives false reassurance. 4. It makes a value judgment.

3. It gives false reassurance. A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament? 1. Highly active 2. Irritable and irregular in habits 3. Negative reaction to new stimuli 4. A positive mild-to-moderately intense mood

3. Negative reaction to new stimuli A slow-to-warm up child may react negatively with mild intensity to any new stimuli or a change. A difficult child is highly active as well as irritable and irregular in habits. An easy child usually has a positive mild-to-moderately intense mood.

Which interventions should the nurse perform when caring for an actively dying client? Select all that apply. 1. Admit the client to hospice care. 2. Draw blood for laboratory tests. 3. Reassure the client and family. 4. Avoid disturbances to the client. 5. Manage the client's symptoms.

3. Reassure the client and family. 5. Manage the client's symptoms. The nurse should provide comfort care for a client who is actively dying by managing the client's symptoms and reassuring the client and family during the dying process. Reassuring the client and family by providing simple bits of information and using therapeutic communication during the dying process can help to reduce their emotional anxiety. Symptom management maximizes the client's quality of life and improves the client family experience with the dying process of a loved one. The client should not be admitted to hospice care while actively dying; there will likely not be enough time and this action could be traumatic for the client and family. A client is admitted to hospice care if they are not actively dying and death is expected within 6 months. The client does not require laboratory tests while actively dying. The client should be repositioned as needed for comfort; for example, placing the head of the bed in the highest position can facilitate breathing comfort.

Which definition is involved in the caring process called knowing according to Swanson's theory of caring? 1. Being emotionally present for the other 2. Sustaining faith in the other's capacity to get through an event 3. Striving to understand an event as it has meaning in the life of the other 4. Facilitating the other's passage through life transitions and unfamiliar events

3. Striving to understand an event as it has meaning in the life of the other In Swanson's theory of caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other's capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other's passage through life transitions and unfamiliar events is related to the caring process called enabling.

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client? 1. Reminiscence 2. Reality orientation 3. Validation therapy 4. Therapeutic communication

3. Validation therapy Validation therapy is the psychosocial concern involved in accepting the descriptive statements made by a confused older client. Reminiscence is recalling the past. Reality orientation involves helping a confused older client agree with the nurse's statements. Therapeutic communication enables the nurse to perceive and respect the older client's uniqueness and healthcare expectations.

A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in what? 1. Bubble wrap/packaging wrap 2. A garbage bag in the trash can 3. A cardboard box with a firmly secured lid 4. A plastic liquid detergent bottle with a screw-top lid

4. A plastic liquid detergent bottle with a screw-top lid Most states (provinces) allow clients to place used needles/pen needles and lancets (sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.

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

4. Accidents, including their prevention Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

On the third postoperative day after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? 1. Explain why there is a need to increase activity. 2. Emphasize that with a prosthesis, there will be a return to the previous lifestyle. 3. Appear cheerful and noncritical regardless of the client's response to attempts at intervention. 4. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

4. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving. The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what? 1. Promoting analgesia and circulation 2. Numbing the nerves and dilating the blood vessels 3. Promoting circulation and reducing muscle spasms 4. Causing local vasoconstriction, preventing edema and muscle spasms

4. Causing local vasoconstriction, preventing edema and muscle spasms Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.

After abdominal surgery a client reports pain. What action should the nurse take first? 1. Reposition the client. 2. Obtain the client's vital signs. 3. Administer the prescribed analgesic. 4. Determine the characteristics of the pain.

4. Determine the characteristics of the pain. The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.

Which statement is true about the nursing model "team nursing"? 1. The registered nurse is responsible for all aspects of client care. 2. Client care can be delegated to other healthcare team members. 3. The registered nurse works directly with the client, family members, and healthcare team members. 4. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

4. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.

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

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

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? 1. Prioritize psychosocial needs over physical needs. 2. Use the Nursing Outcomes Classification (NOC) only. 3. Use nursing knowledge to plan outcomes and disregard client and family desires. 4. Set priorities and outcomes using the client's and family input.

4. Set priorities and outcomes using the client's and family input. Outcomes should be set with the client and family, if feasible, just as priorities of interventions are considered with the client and family when possible. Physical needs should be met before psychosocial needs. Outcomes may be developed using two methods: writing specific outcome statements or choosing outcomes from the NOC.