FUNDAMENTALS
The nurse offers a client items to perform oral care before breakfast. The client refuses the care, stating, "I prefer to brush my teeth after my meal." Which of the following statements by the nurse is most appropriate?
"I will note on your chart that you prefer oral care after meals." Rationale: Client choice is always a priority when providing care. The other answers do not allow for client choice in deciding when oral hygiene is performed.
Clozapine therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, "Why do I have to have a blood test every week?" Which response by the nurse would be most appropriate?
"Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Rationale: The client needs specific information about the effects of the drug, specifically that the drug can cause agranulocytosis. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure follow-up with the required protocol for clozapine therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication. The supply of medication is not dependent on blood testing. Telling the client that the health care provider (HCP) wants to know the progress does not provide specific information for this client. The blood tests are not required by the drug company.
A client with chronic renal failure was recently told by the healthcare provider of being a poor candidate for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate? Select all that apply.
-Take a seat next to the client and sit quietly to reflect on what was said. - Say to the client, "You're feeling upset about the news you got about the transplant." Rationale: Silence is a therapeutic communication technique that allows the nurse and client to reflect on what has taken place or been said. By waiting quietly and attentively, the nurse encourages the client to initiate and maintain conversation. By reflecting the client's implied feelings, the nurse promotes communication. Using such platitudes as "We all have days when we don't feel like going on" fails to address the client's needs. The nurse shouldn't leave the client alone because he might harm himself. Reminding the client of the treatment frequency doesn't address his feelings.
The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply.
-suicide or self-harm ideation -recent use of substances of abuse -allergic reactions or adverse drug reactions Rationale: When assessing client safety, the nurse assesses suicide thoughts or plan, recent use of illicit drugs (as they may cause impaired judgment or thought processes), and previously experienced allergic reactions and adverse reactions to medications. Note that safety involves many aspects of care. Incentives and diet preferences (allergies would be previously noted) are not directly related to safety, although they may be part of an overall assessment.
What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis?
Achieving a controlled level of pain and fatigue throughout the day. Rationale: Symptoms of rheumatoid arthritis include localized pain, stiffness, and decreased joint mobility after a period of rest, such as after sleeping. This can be more localized, which causes symptoms such as pain or stiffness. Lack of mobility over a period of time can increase the symptoms. Other answers are incorrect because they do not reflect management of care. Working on a positive self image is about self esteem. Always performing activities of daily living does not reflect promoting management; clients do not need to be independent. Accepting and working toward understanding is not about management.
Which of the following nursing actions would be most beneficial to a client and her husband who state they wish to go through labor without the use of analgesics or anesthetic agents?
Act as an advocate for the couple and verbalize their wishes to nurses and physicians. Rationale:Nurses are ethically responsible for giving childbearing families the autonomy to make informed choices about the care they receive. This also fosters a collaborative relationship with the family. Nurses must advocate for women to have autonomy in decision making and provide respect and informed choice to ensure that women and their families are empowered to take responsibility to make decisions. It is the nurse's role to guide and support choices rather than direct. A woman should never be left alone in labor. Providing information about or encouraging the use of drugs may leave the client and family feeling as though the nurse is not supportive of the couple's choices by encouraging actions that are contradictory to the family's birth plan.
A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse?
Call the physician to report the finding. Rationale: The best response would be to notify the physician. The nurse cannot repeat the dose of analgesia without an order. Massaging the ankle and applying moist heat would be inappropriate for a number of reasons. The client could be developing a deep vein thrombosis, which may dislodge an embolus. Unrelieved pain indicates that an adverse event is developing, and the physician should be made aware of the situation.
A client is transferred to the acute stroke unit. The nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care and is aware this information indicates which of the following regarding a client's clinical status?
Changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person Rationale: This is the correct choice, as it offers specific measurable data about the client. The other choices are not complete neurologic assessments.
Communication is very important when preparing a client for a mastectomy. What are primary issues for the nurse to discuss?
Concerns regarding the cancer and how the surgery will affect the client Rationale: Two primary concerns are the confirmation of cancer and the impending mastectomy. The other choices although correct are not the primary concern at this time.
A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention?
Control the pain and support breathing and oxygenation. Rationale: Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.
A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?
Cullen's sign Rationale: Cullen's sign is evidenced by discoloration at the periumbilical area. This sign may indicate an underlying subcutaneous intraperitoneal hemorrhage. Chvostek's sign is a facial nerve spasm and Trousseau's sign is a carpopedal spasm; both signs occur with hypocalcemia. Broca's area, not sign, is an area within the brain that controls the motor functions involved in speech.
Which statement is a correct reason for nurses to become culturally sensitive and develop their cultural competency skills?
Cultural sensitivity and consideration of client diversity are necessary to provide ethical nursing care. Rationale: Becoming sensitive to clients of different cultural backgrounds is necessary in order to provide ethical care. In addition, nurses must develop cultural competency to care for these clients effectively. People of different cultures make the decision of acculturation or preservation of their own culture. A nurse cannot be familiar with beliefs of all subcultures; however, it is important to have a framework for better understanding and appreciating persons from different cultures. Codes of ethics challenge nurses to provide ethical care, but this does not explain the relationship between ethical care and culturally-sensitive care.
The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?
Palpate for the bladder above the symphysis pubis Rationale: Anesthesia may cause urinary retention. The kidneys typically produce 35-55 mL of urine per hour; when full, the bladder becomes palpable above the symphysis pubis. The first step is to assess if the bladder is distended by palpating the suprapubic area. The other actions would not be appropriate actions.
A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained?
Development of an increase in mobility Rationale: This plan of care will help limit bone demineralization and reduce osteoporotic pain, thus promoting increased activity. The other choices are not reflective of osteoporosis.
In which way does a nurse play a key role in error prevention?
Identifying incorrect dosages or potential interactions of ordered medications Rationale: The nurse must be knowledgeable about drug dosages and possible interactions when administering medications; she must follow appropriate policies to correct dosage errors or prevent potential interactions. The nurse is responsible for questioning unclear or ambiguous physician's orders and should never carry out an order with which she's uncomfortable. OSHA establishes comprehensive safety and health standards, inspects workplaces, and requires employers to eliminate safety hazards but notifying OSHA of medication errors doesn't resolve the problem. The client should be aware of his rights as a client, but that awareness doesn't play a key role in error prevention.
A nursing instructor has assigned a student to care for a client of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preferences are important for the student to consider when caring for this client?
People of Asian descent prefer some distance between themselves and others. Rationale:Clients of Asian descent are more comfortable with some distance between themselves and others. Direct eye contact may be considered impolite or aggressive within the Asian culture, and they may tend to avoid direct eye contact and avert their eyes while speaking with another.
A school nurse is called to assess a 12-year-old child with type 1 diabetes mellitus who is experiencing lightheadedness, tachycardia, pallor, headache, and confusion during gym class. What is the priority action by the nurse?
Provide a snack of hard candy or raisins. Rationale: The increased exercise has caused a drop in serum glucose levels, producing symptoms of hypoglycemia. The first action is to give the child a sugary snack to raise the glucose level.
The nurse is completing a neurologic assessment on a client who has been admitted with a contusion to the brain. Which of the following findings would warrant further action?
Pupils are equal and sluggish in reaction to light. Rationale: Assessing the pupillary response is an important consideration in neurologic assessment. When pupils are sluggish to respond, this indicates neurologic impairment. The Glasgow Coma Scale is used to assess the extent of neurologic impairment. Each of the other findings indicates a normal response to stimuli. Vital signs are normal.
Which of the following indicates that the client with Addison's disease is receiving too much glucocorticoid replacement?
Rapid Weight Gain. Rationale: Rapid weight gain, because it reflects excess fluids, is a warning sign that the client is receiving too much hormone replacement. It may be difficult to individualize the correct dosage for a client taking glucocorticoids, and the therapeutic range between underdosage and overdosage is narrow. Maintaining the client on the lowest dose that provides satisfactory clinical response is always the goal of pharmacotherapeutics. Fluid balance is an important indicator of the adequacy of hormone replacement. Anorexia is not present with glucocorticoid therapy because these drugs increase the appetite. Dizziness is not specific to the effects of glucocorticoid therapy. Poor skin turgor is a late sign of fluid volume deficit.
Which is the correct technique when the nurse is applying an elastic bandage to a leg?
Start at the distal end of the extremity and move toward the trunk. Rationale: When applying an elastic bandage to a leg, start at the distal end and move toward the trunk in order to support venous return. Tension should be kept even and not increased with each turn to prevent circulatory impairment. Overlapping each layer twice when wrapping can also impair circulation. The clips securing the bandage should be placed on the outer aspect of the leg to avoid creating a pressure point on the other leg.
For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing?
The granulation tissue is at the wound edges. Rationale: Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing. Surrounding tissue which is red and hot is more indicative of infection.
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message: "You are not authorized to view this information." What is the reason for this message?
The laboratory assistant can retrieve medical records but cannot view the details. Rationale: It is important to block the type of information that personnel in various departments can retrieve. Laboratory assistants can retrieve information from the medical records, but they cannot view information in the client's personal history. Even if the laboratory assistant had the correct access number and the password or was trying to view archived data, he or she would not have been able to access a client's personal history.
Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful?
maintenance of joint mobility Rationale: The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone.
The nurse refers the parents of a child with cystic fibrosis to an organization that helps families with children who have this disease. Such organizations are especially beneficial for parents by helping them:
meet with other parents of children with cystic fibrosis for mutual support. Rationale: An important function of support organizations for any health problem is to put parents of children with the condition in touch with each other. Other parents can commonly offer support and help. In some instances, organizations can offer assistance, such as providing equipment required for home care of their child with cystic fibrosis. These organizations do not obtain tutors for children, nor do they provide medications, financial assistance, or genetic counseling for parents.
A nurse measures a client's apical pulse rate and compares it with his radial pulse rate. The differential between these two pulses is called:
the pulse deficit. Rationale: The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the differential between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent.
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
-Place each item of clothing in a separate paper bag. -Hang wet clothing to dry. Rationale: Preserving forensic evidence is essential for investigative purposes following injuries that may be caused by criminal intent. The nurse should put each item of clothing in a separate paper bag and label it; wet clothing should be hung to dry. The nurse should not cut or otherwise unnecessarily handle clothing, particularly clothing with such evidence as blood or body fluids. The nurse should document carefully the client's description of the incident and use quotes around the client's exact words where possible. The documentation will become a part of the client's record and can be subpoenaed for subsequent investigation. The nurse should not handle bullets from the client because they are an important piece of forensic evidence.
The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply.
-Report signs of redness or inflammation at the site. -Call the health care provider (HCP) for a temperature above 100° F (37.8° C). -Cleanse the port with alcohol wipes. Rationale: When intravenous (IV) therapy must be administered in the home setting, teaching is essential. Written instructions, as well as demonstration and return demonstration help reinforce key points. The client and/or caregiver is responsible for adhering to the established plan of care that includes the treatment plan, monitoring plan, potential for complications, expected outcome/s, potential adverse effects, and plan for communicating with the HCP. Periodic laboratory testing may be necessary to assess the effects of IV therapy and the client's progress. The client should report signs of redness or inflammation that could indicate infection, and also report an elevated temperature. Prior to changing the fluids, the caregiver should cleanse the port with alcohol wipes. It is not necessary to use sterile gloves; the IV bag should be elevated to promote gravity flow.
Which of the following is a cultural norm of the healthcare system?
There is the use of a systematic approach and problem-solving methodology. Rationale: Cultural norms of the healthcare system include the use of a systematic approach and problem-solving methodology; the omnipotence of technology; the dislike of tardiness, disorderliness, and disorganization; and the use of certain procedures attending birth and death.
A client reports for a preoperative appointment in preparation for surgery that will change the client's body from female to male. The client, who was born biologically female, has expressed to the nurse and physician the wish to have been born with the body of a man. What identity is the client demonstrating?
Transsexual. Rationale: A transsexual is a person of a certain biologic gender who has the feelings of the opposite sex and of being within the body of the wrong sex. For many transsexuals, the solution is to change their bodies. A homosexual experiences sexual fulfillment with a person of the same gender. A bisexual finds pleasure with both opposite-sex and same-sex partners. A transvestite desires to take on the role or wear the clothes of the opposite sex.
A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response?
Approach the client and ask if there are questions about the condition. Rationale: This is the best therapeutic response that is client focused. The other answers do not demonstrate therapeutic response: nurses should not offer false assurances, and calling the family is not addressing the problem between nurse and client.
A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which order should the nurse anticipate?
ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel. Rationale: An ECG evaluates the report of chest pain, laboratory tests determine anemia, and the test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and LD levels are appropriate for a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.
A community health nurse is planning to address the physical needs of older adults living in their homes. What primary areas would be included in this discussion?
Importance of exercise, balanced nutrition, mobility and safety needs Rationale: This choice provides teaching regarding health promotion and illness and injury prevention for elderly clients living in their homes. It is important to ensure that elderly clients are meeting their needs of exercise, nutrition, mobility, and safety to be able to manage in their own homes. These are the primary physical needs that could pose problems for elderly clients. Assessment of mobility patterns focuses only on mobility. Social support systems do not address physical ones. By this time, prevention of deficits is difficult; aids to support adequate hearing and seeing are more practical. Physician visits are important, but they focus on health problems more than on meeting physical needs.
In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that she has made. The nurse is most clearly demonstrating which of the following professional values?
Integrity. The nurse is demonstrating integrity, which is defined as acting in accordance with an appropriate code of ethics and accepted standards of practice. Seeking to remedy errors made by self or others is an example of integrity. Altruism is a concern for the welfare and being of others. Social justice is upholding moral, legal, and humanistic principles. Human dignity is respect for the inherent worth and uniqueness of individuals and populations.
A client rates the pain level of a migraine an 8 on a scale of 1-10. How would the nurse administer the medication to give the client the quickest relief?
Intravenous. Rationale: The nurse would want the client to receive the benefit of the medication as quickly a possible to help alleviate the migraine. A drug placed directly into intravenous system enters the client's bloodstream more quickly than oral, IM, or buccal, thereby avoiding the barriers of food and the destructive effects of stomach acid. With oral, IM, and buccal administration, the client's response to the drug is slower.
During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?
Introducing new issues to the client Rationale:The nurse shouldn't introduce new issues during the termination phase because doing so may confuse the client. This phase is a time for wrapping up the relationship. It's appropriate for the nurse to refer the client to support groups. Reviewing what's been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, but this is a normal response.
A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action should the nurse include in the care plan?
Involving the family and the client in planning care. Rationale: For a client with a nursing diagnosis of Social isolation, interventions include involving the family and the client in planning care and encouraging visits from family members and friends. Banning personal belongings from the bedside would increase the client's feelings of isolation. The nurse should provide simple, not detailed, explanations to the client and his family because stress may have diminished their comprehension. The nurse should encourage the family to visit as often as the client's condition permits.
Which guidelines define and regulate what the nurse may and may not do as a professional?
Nurse practice act Rationale: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.
A healthcare provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which of the following orders should the nurse question?
Oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air Rationale: People with COPD retain CO2, which is the normal trigger for respiratory rate. In clients with COPD and high levels of CO2, oxygen levels trigger breathing. Too much oxygen and the body slows breathing. Clients with COPD may quit breathing completely when given oxygen at very high levels (greater than 2 L).
A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks the client if he/she has an advanced directive. The client asks for an explanation of advanced directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is:
a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. Rationale: A facility refers to an advance directive, a document the client writes or completes, to provide care at a time when the client cannot make his/her own choices. The living will and health care proxy are both examples of advance directives. A living will is a document which a competent adult prepares and which provides direction regarding medical care if the client becomes incapacitated. Health care proxy is an authorization enabling any competent individual to designate someone else to exercise decision-making authority on the individual's behalf under specific circumstances.
A nurse is planning care for an elderly client with cognitive impairment who is still living at home. Which action should the nurse identify as a priority for safety in planning care for this client?
ensuring the removal of objects in the client's path that may cause him to trip Rationale: When caring for a client with cognitive impairment, the priority is to ensure that all objects in the client's path are removed to prevent the client from falling. Additional measures, such as having two people accompany the client when he ambulates, placing his favorite things in safekeeping, and giving medications in a liquid form to be sure he swallows them, are less crucial.
The nurse is assigning care to the unlicensed assistive personnel (UAP) for a client with a nasogastric tube with intermittent suction after gastric surgery. Which tasks cannot be delegated to the UAP?
repositioning the tube Rationale: Repositioning the tube in a client who has undergone gastric surgery should be performed (per prescription of the surgeon) by the registered nurse. Recording output, securing the nasal tape, cleansing the nares, and documenting the color of the drainage could safely be delegated to the UAP.
The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:
to the client from sources outside the client's environment. Rationale: The primary purpose of reverse isolation is to reduce transmission of organisms to the client from sources outside the client's environment.
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:
write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. Rationale: To ensure client safety, the nurse should first write the results on the medical record, then read them back to the caller and wait for the caller to confirm that the nurse has understood the results. Using scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via e-mail is unacceptable due to potential security and privacy issues.
