fundamentals HESI

A nursing student and a preceptor nurse are discussing nursing liability. Which statement if made by the student would indicate to the nurse that the student understands the concept of liability? a) "A client can still file a lawsuit outside of the statute of limitations if the the discovery of the harm has been more recent." b) "A client has 5 years to sue if they feel they have been harmed." c) "There is a grace period of 1 year after a client is injured and when they can file a law suit." d) "A form of alternative dispute resolution is to have a client sign a waiver before treatment that indicates he or she cannot sue in case of error."

"A client can still file a lawsuit outside of the statute of limitations if the the discovery of the harm has been more recent." Correct Explanation: Statute of limitations is the time period during which the injured party must file a case. Discovery rule refers to the time when the client discovers the injury. The statute of limitations typically allows clients to file a lawsuit within 2 years of discovery; however, the time may vary from state to state. Grace period refers to the contractually specified time during which payment is permitted, without penalty, beyond the due date of the debt. Alternative dispute resolution refers to any means of settling disputes outside the courtroom setting

A nurse reports to the hospital occupational health nurse (OHN) that he/she was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when he/she will know whether he/she is positive or negative for HIV infection. Which of the following is the most appropriate response by the OHN? a) "The test results will vary during the first year of testing for the disease." b) "We will test you in 4 weeks, and then we will have a definitive answer." c) "Accurate results will be obtained by testing at 3 months and again at 6 months." d) "Most nurses who have been splashed do not test positive if they wash immediately."

"Accurate results will be obtained by testing at 3 months and again at 6 months." Correct Explanation: Ninety-five percent of exposed individuals will seroconvert within 3 months; 99% will convert by 6 months. The other options do not accurately reflect the timeline for seroconversion following exposure.

An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual's assertion? a) "Research has shown the nature of sexual activity changes with age but that it actually becomes more frequent." b) "That's true, but it's important for us to give them the teaching they need in order to resume this part of their relationship." c) "Actually it's not true that older people always stop having sexual activity when they get older." d) "It's true that they've probably stopped having sexual activity, but it's important for them to have companionship."

"Actually it's not true that older people always stop having sexual activity when they get older." Correct Explanation: Sexual activity need not be hindered by age. There is no evidence, however, that it becomes increasingly frequent in late adulthood.

When evaluating a client's preoperative cognitive-perceptual pattern, which question should the nurse ask the client? a) "Do you have difficulty swallowing?" b) "Do you need special equipment to walk?" c) "Do you smoke?" d) "Do you wear glasses?"

"Do you wear glasses?" Explanation: The nurse would ask the client whether he wears glasses to evaluate his preoperative cognitive-perceptual pattern. Asking about the client's swallowing pattern would evaluate his nutritional-metabolic pattern. Asking about his need for special equipment to walk would evaluate his activity-exercise pattern. Asking the client about his history of smoking would evaluate his health perception-health management pattern

Which of the following assessment questions is most likely to yield clinically meaningful data about a female client's sexual identity? a) "Have you ever had any sexually transmitted diseases in the past?" b) "Do you find that your health allows you to enjoy a meaningful sex life?" c) "How do you feel about yourself as a woman?" d) "Are you satisfied with the quality of your relationships right now?"

"How do you feel about yourself as a woman?" Correct Explanation: Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships. Asking an open-ended question about how the client feels about herself as a woman is likely to elicit important insights. Assessing the client's history of STIs does not directly address her sexual identity.

Which question would the nurse ask to determine a client's coping abilities during a lengthy hospital stay? a) "How is this illness impacting you and your family?" b) "What are the worst challenges that you have faced?" c) "What could you have done to prevent this illness?" d) "How can we take away your worries while you are in the hospital?"

"How is this illness impacting you and your family?" Correct Explanation: This question helps address how illness affects the client as well as the family. This question seeks to assess the impact of the stressor and coping abilities. It also examines how the support system, the family, is responding. It is too late to address prevention issues. Taking away worries is not realistic because the client needs to work through concerns. Asking about worst challenges changes the topic of what the client is experiencing right now

On entering the room of a client who has undergone a dilatation and curettage (D&C;) for a spontaneous abortion, the nurse finds the client crying. Which comment by the nurse would be most appropriate? a) "Commonly spontaneous abortion means a defective embryo." b) "It is important that you do not try to get pregnant too soon." c) "Are you having a great deal of uterine pain?" d) "I am truly sorry you lost your baby."

"I am truly sorry you lost your baby." Explanation: The death of a fetus at any time during pregnancy is a tragedy for most parents. After a spontaneous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as "I am truly sorry you lost your baby" is most appropriate. Therapeutic communication techniques help the client and family understand the meaning of the loss, move less stressfully through the grief process, and share feelings. Asking the client whether she is experiencing a great deal of uterine pain is inappropriate because this is a "yes-no" question and doesn't allow the client to express her feelings. Saying that the embryo was defective is inappropriate because this may lead the client to think that she contributed to the fetus's demise. This is not the appropriate time to discuss embryonic or fetal malformations. However, the nurse should explain to the client that this situation was not her fault. Telling the client that she should not get pregnant again too soon is not therapeutic and discounts the feelings of the expectant mother who had already begun to bond with the fetus

A client is placed on a low-sodium (1500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective? a) "I chose broiled chicken with a baked potato for dinner." b) "I chose a tossed salad with olives and oil and vinegar dressing for lunch." c) "I can still eat a ham and cheese sandwich with pickles for lunch." d) "I will have bacon and eggs for breakfast every day."

"I chose broiled chicken with a baked potato for dinner." Correct Explanation: The client's choice of a baked potato with broiled chicken indicates effective nutrition teaching because potatoes and chicken are relatively low in sodium. Ham, pickles, olives, and bacon are all extremely high in sodium and should not be included in a low-sodium diet.

The nurse is caring for a client who developed fluctuating moods related to a recent cerebral vascular accident. When discussing the client's mood in a family meeting, which statements confirm a family's understanding of how to support the client? Select all that apply. a) "I allow her to vent feelings and then find a different topic to discuss." b) "All the kids just leave the room if she gets emotional, that provides privacy." c) "I tell her how I feel and yell back if needed so not to keep all of my frustration inside." d) "I do not take what she says personally and try to address the issue of anger." e) "Sometimes I sit down and cry too then we pick ourselves up and move on."

"I do not take what she says personally and try to address the issue of anger." • "I allow her to vent feelings and then find a different topic to discuss." • "Sometimes I sit down and cry too then we pick ourselves up and move on." Explanation: Changes in the brain which occur following the cerebral vascular accident can lead to periods of an emotional outburst resulting in anger or depression. Family may experience changes in their loved one which include uncharacteristic verbal outbursts or crying within usual conversation. It is important to identify that these outburst are a result of the illness and not take the outburst personally. Allowing the client to vent her feeling and experience the frustration with the client allows for the sharing of emotions and provides emotional support. Afterwards, moving on to a different topic or moving on within the day's activity does not allow the client to remain in the emotional state. Leaving the client or yelling at the client is not therapeutic to support the client through this time

A client asks the nurse how frequently she should have a mammogram. The nurse assesses that there is no family history of breast cancer and no risk factors with this particular client. Which statement, if made by the client, shows an understanding of the nurse's teaching regarding the frequency of mammograms? a) "I should have a mammogram twice yearly until age 50, then only yearly." b) "I should have a mammogram every year beginning at age 40." c) "I should have a mammogram once a year at age 40, then annually." d) "I should have a mammogram only if I find a lump after self-breast examination."

"I should have a mammogram every year beginning at age 40." Explanation: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks exist, such as family history, genetic tendency, or past breast cancer, more frequent examinations may be necessary.

An anxious client asks the nurse for the results of recent blood work and wants to know what the results mean. Which of the following responses by the nurse is the most appropriate? a) "I can't tell you the exact results, but I have seen them and they are okay." b) "Let me get your chart so that I can give you the results and tell you about them." c) "I understand your concern. I'll call the physician to review the results with you." d) "Don't worry. If anything were wrong, the physician would have told you."

"I understand your concern. I'll call the physician to review the results with you." Correct Explanation: It is not within the nurse's scope of practice to provide clients with diagnoses based on laboratory results. The nurse should advocate for the client to receive the results from the physician and facilitate that discussion. The other options are incorrect because the nurse is providing information that the nurse is not permitted to release. Stating that the client should "not worry" will not address the client's anxiety about receiving the results (and interpretation) of the lab work.

The son of an elderly client who has cognitive impairments approaches the nurse and says, "I'm so upset. The health care provider (HCP) says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment? a) "Boy, I have a lot to think about before I see the social worker tomorrow." b) "I want the social worker to make this decision so Dad will not blame me." c) "I am so afraid of making the wrong decision, but I can move him later if I need to." d) "I think I can handle most of Dad's needs with the help of some home health care."

"I want the social worker to make this decision so Dad will not blame me." Correct Explanation: Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

The client has various sensory impairments associated with type 1 diabetes. The nurse determines that the client needs further instruction when the client says: a) "I will avoid kitchen activities." b) "I will carefully test the temperature of my bathwater." c) "I will avoid hot water bottles or heating pads." d) "I will inspect my skin daily for pressure points and injury."

"I will avoid kitchen activities." Correct Explanation: Safety concerns are essential for a client with sensory impairment. Water temperature should be tested carefully, hot water bottles should be avoided, and the skin should be inspected regularly. Independence and self-care are also important; the client should not be instructed to avoid kitchen activities out of fear of injury.

The nurse is instructing an unlicensed assistive personnel (UAP) on the prevention of postoperative pulmonary complications. Which statement indicates that the UAP has understood the nurse's instructions? a) "I should suction the client every 2 hours." b) "I will keep the client's head elevated." c) "I will have the client take 5 to 10 deep breaths every hour." d) "I will turn the client every 2 hours.

"I will have the client take 5 to 10 deep breaths every hour." Explanation: Having the client deep breathe hourly is the most appropriate action for the UAP to take to help prevent pulmonary complications. The client should be turned at least every 2 hours or as needed for this particular client. Keeping the client's head elevated will not prevent pulmonary complications. Suctioning the client is not a UAP's responsibility, nor does it prevent pulmonary complications

The client who has a history of angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that she will have to wait to have her medication refilled. Which response by the nurse is most appropriate? a) "Come back tomorrow and your medication will be ready." b) "I will not continue to talk with you if you curse." c) "I am sorry if you cannot wait." d) "You are being very childish."

"I will not continue to talk with you if you curse." Explanation: Stating, "I will not continue to talk with you if you curse," sets limits on the client's behavior and points out the negative effects of her behavior. Therefore, this response is most appropriate and therapeutic. The statement, "You are being very childish," reprimands the client, possibly causing the anger to escalate. The statement, "I am sorry if you cannot wait," fails to provide feedback to the client about her behavior. The statement, "Come back tomorrow and your medication will be ready," ignores the client's behavior, failing to provide feedback to the client about the behavior. It also shows poor nursing judgment because the client may need her medication before tomorrow or may not return to the clinic the following day.

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which statement made by the nurse is appropriate? a) "Give him time. He will get over it." b) "I would like to refer you to a support group so that you can speak with others with similar problems." c) "We have a psychiatrist available for sexual dysfunction therapy." d) "Let me speak with your husband. He might be okay with it."

"I would like to refer you to a support group so that you can speak with others with similar problems." Correct Explanation: Having this client speak with someone who has had a similar surgery and concerns would be beneficial. Discussing the client's concerns with her husband does not address the client's needs. She is coping normally and does not need professional help. In fact, the client may feel that the nurse violated confidentiality.

A 19-year-old client has undergone an examination and had evidence collected after being raped. Her father is overheard yelling at his daughter, "You are going to tell me who did this to you. What is his name?" Which is the nurse's best response? a) "Please be quiet. You are not helping your daughter this way." b) "Stop yelling. You are being inappropriate." c) "Please come with me, sir. I need some important information." d) "If you do not stop yelling, I will have to call Security."

"Please come with me, sir. I need some important information." Correct Explanation: With this level of anger in a crisis, the father needs simple but firm directions to leave the room, calm down, and then to talk. Doing so relieves the daughter of any pressure from her father. Telling the father to stop yelling or be quiet provides no concrete directions to the father and may embarrass him in front of his daughter. Telling the father that if he does not stop yelling, the nurse will call Security is a threat, possibly leading to an escalation of the situation.

A client with bleeding esophageal varices and cirrhosis of the liver due to alcoholism asks the nurse, "Will I survive and make it out of the hospital? One of my friends died from the same problem." What is the best nursing response to the question? a) "That's a difficult question to answer, and this must be very frightening for you." b) "Chronic alcoholism has serious consequences, and you may have the same outcome as your friend." c) "You'll be okay after the physician gets the bleeding under control." d) "What makes you think you're not going to make it?"

"That's a difficult question to answer, and this must be very frightening for you." Correct Explanation: This answer is an honest response that acknowledges the client's fears and concerns, yet does not give false reassurance.

A nurse is assessing a client using light palpation. How does a nurse perform light palpation? a) By indenting the client's skin 1″ and then releasing the pressure quickly b) By indenting the client's skin 1″, using both hands c) By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm) d) By indenting the client's skin 1″ to 2″ (2.5 to 5 cm)

By indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm) Correct Explanation: To perform light palpation, the nurse indents the client's skin ½″ to ¾″, using the tips and pads of her fingers. She indents the skin approximately 1½″ (3.8 cm) when performing deep palpation. She indents the skin 1″ and then releases the pressure quickly when eliciting rebound tenderness

A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states "a left lumbar laminectomy of L3-L4." What should the nurse do next? a) Change the consent form. b) Call the surgeon. c) Review the client's history. d) Have the client sign the consent form.

Call the surgeon. Explanation: Based on the client's comments, the nurse should call the surgeon to verify the location of the surgery. The client's comments indicate radiculopathy of L4-L5, but the informed consent form states L3-L4. Radiculopathy of L3-L4 involves pain radiating from the back to the buttocks to the posterior thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history is contradictory, the health care provider (HCP) should be contacted to clarify the situation. Ultimately, it is the surgeon's responsibility to identify the site of surgery specified on the surgical consent form

The nurse-manager on a gynecologic surgical unit is addressing reports from clients that they have to wait too long on the night shift for their pain medication. Which course of action should the nurse-manager take first? a) Change the staffing schedule on nights to include a medication nurse. b) Consult the nurses on the evening shift about their evaluation of the night nurses regarding these concerns. c) Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity. d) Consult the nursing supervisor.

Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity. Correct Explanation: To determine the cause of this problem, a quality improvement study should be conducted. Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. Consulting with the evening nurses may result in biased observations because the evening nurses are not conducting care under the same environment as the night nurses. Including a medication nurse is not the first step in understanding the problem and may be an unrealistic or expensive solution. The supervisor is not directly involved with the problem and should only be consulted if the problem cannot be solved by those involved. (

The son of a dying patient is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation? a) Contact the chaplain to arrange a visit with the patient. b) Document the patient's request and wait to see if she reiterates her request. c) Perform a detailed spiritual assessment of the patient. d) Organize a meeting between the chaplain, the son, and the patient to achieve a resolution.

Contact the chaplain to arrange a visit with the patient. Correct Explanation: The nurse's primary duty is to honor the patient's request for a meeting with a spiritual adviser.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse? a) Irrigate the nasogastric tube by following the steps outlined in the procedure manual. b) Contact the nurse educator for an in-service and support in performing the skill. c) Ask another nurse to irrigate the nasogastric tube for him/her each time it is required. d) Refuse the assignment because he/she has never irrigated a nasogastric tube.

Contact the nurse educator for an in-service and support in performing the skill. Correct Explanation: The nurse has a responsibility for recognizing his/her limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide inservice and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in his/her learning or expertise.

The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process? a) Ask the nurse-managers at the best facilities for their policies and procedures so she can adopt them. b) Ask the staff nurses to form a task force to review and revise discharge policies and procedures. c) Ask her staff nurses to investigate discharge policies and procedures at other outpatient facilities and recommend changes. d) Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility.

Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. Correct Explanation: Benchmarking is a good approach for the nurse-manager to take. Benchmarking is the process of comparing an organization's delivery of client care practices in one organization to those in the best health care organizations. Because the nurse-manager already has contacts at the best facilities, she's the most appropriate person to obtain the necessary information. The nurse-manager, however, shouldn't automatically change her policies and procedures to match those of the best facilities. Instead, she should evaluate the policies to determine which ones might be implemented at her facility. Then she and her staff should make appropriate recommendations for change. Asking her staff to form a task force is a good idea, but benchmarking saves time and effort and enables the nurse-manager to obtain information from excellent resources.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take? a) Report to the nurse manager that the nurse needs guidance on documentation b) Strike through the entry ensuring the original entry is still visible c) Rewrite the entry on the correct health record indicating who made the error d) Contact the previous nurse requesting that the nurse correct the error

Contact the previous nurse requesting that the nurse correct the error Correct Explanation: The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.

A client, age 22, is admitted in a psychotic episode. His frequent requests to speak with the hospital chaplain are interspersed with profanities regarding God and the devil. The most therapeutic nursing intervention would be to: a) Ask a chaplain to meet with you and the client on the unit so you can monitor the exchange. b) Immediately call the chaplain, because you realize symptoms may resolve with spiritual counseling. c) Continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis. d) Tell the client you are not allowed to call the chaplain when a client is this disturbed.

Continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis. Correct Explanation: Safety is the nurse's first priority. The client is experiencing altered thought processes and is unlikely to be able to distinguish his spiritual beliefs at this time. Remediation: Communicating with difficult patients

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse? a) Refuse to provide care while the client is handcuffed to the stretcher. b) Call the supervisor and report the officer's decision to keep the cuffs on. c) Continue to assess the client, allowing the officer to assume responsibility for the restraint. d) Ask the physician for an order to remove the handcuffs.

Continue to assess the client, allowing the officer to assume responsibility for the restraint. Correct Explanation: In this situation, the police officer has applied the restraint and has taken responsibility for the restraint. The nurse should assess the client for any potential complication from the handcuffs, document the assessment, and provide care to the client as usual. The other options are incorrect because the police officer has assumed responsibility for the restraint. It is unlikely that a physician would order the restraint to be removed against the officer's recommendation, and if the restraints are in place and the officer is present, the nurse can provide care to the client.

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? a) Call the physician and obtain an order for a fluid bolus. b) Call the physician and obtain an order for a diuretic. c) Continue to monitor the client as ordered. d) Rezero the equipment and take another reading.

Continue to monitor the client as ordered. Correct Explanation: Normal CVP ranges from 3 to 7 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to rezero the equipment. Calling a physician and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 3 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 7 mm Hg.

A patient from Pakistan informs the nurse of his cultural dietary requests. The nurse responds to the special dietary needs by stating, "You are now living in the United States, and you should try to start eating those foods common to an American diet." This inappropriate response is an example of: a) Cultural diversity. b) Cultural imposition. c) Cultural assimilation. d) Cultural blindness.

Cultural imposition. Correct Explanation: The nurse's response is an example of cultural imposition, which is defined as the belief that everyone should conform to the majority belief system. Cultural blindness is the result of ignoring differences and proceeding as though they do not exist. In this situation, the nurse did not ignore the request but inappropriately responded to it. Cultural diversity is defined as a diverse group in society, with varying racial classifications and national origins, religious affiliations, languages, physical sizes, genders, sexual orientations, ages, disabilities, socioeconomic statuses, occupational statuses, and geographic locations. Cultural assimilation occurs when members of a minority group live within a dominant group and lose the cultural characteristics that make them different.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? a) The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange. b) There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. c) The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. d) The alveoli expand and increase the lung surface available for ventilation.

Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? a) Deficient fluid volume b) Excess fluid volume c) Impaired urinary elimination d) Imbalanced nutrition: Less than body requirements

Deficient fluid volume Correct Explanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? a) Excess fluid volume b) Impaired urinary elimination c) Deficient fluid volume d) Imbalanced nutrition: Less than body requirements

Deficient fluid volume Correct Explanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema

In anticipation of discharge, a nurse is teaching the daughter of an elderly woman how to change the dressing on her mother's venous ulcer. Which of the following teaching strategies is most likely to be effective? a) Provide explicit written and verbal instructions, and ask the daughter to explain back to the nurse how she would perform the dressing change. b) Demonstrate and explain the procedure, and then have the daughter perform it. c) Explain the procedure clearly and slowly while providing multiple opportunities for the daughter to ask questions. d) Use a multimedia strategy that combines animation with narration.

Demonstrate and explain the procedure, and then have the daughter perform it. Correct Explanation: All steps of a procedure such as a dressing change should be demonstrated, practiced, and provided in writing. The client or caregiver should then perform the procedure or treatment in the presence of the nurse to demonstrate his or her understanding and ability to carry out the procedure. This is more likely to facilitate success than providing a passive multimedia resource, explaining, or providing written instructions alone without reciprocal demonstration.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an assessment. The nurse then informs the physician and the nursing supervisor about this incident and also completes an incident report. Which of the following actions by the nurse indicates correct knowledge of handling an incident report? a) Documents a complete description of the happenings in the client's records. b) Makes a copy of the incident report and places it in the client's records. c) Makes a copy of the incident report to give to the physician. d) Mentions in the client's report that an incident report was completed.

Documents a complete description of the happenings in the client's records. Correct Explanation: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record. The incident report is a legal document, and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report

A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse? a) Explore other ways to control symptoms and address the family's concerns more effectively. b) Reinforce the meaning of supportive care to the family and restrict their visits so the client has more rest time. c) Provide support for the family and encourage the client to become more actively involved in the care. d) Determine where the client is regarding the stages of dying and discuss the findings with the family.

Explore other ways to control symptoms and address the family's concerns more effectively. Correct Explanation: Trying other nursing measures may more effectively relieve the client's distress. These need to be explored. It is important to examine other ways to alleviate the other symptoms by ensuring rest periods just prior to eating and better pain management. In addition, it is the nurse's role to advocate and to support the client while explaining what is happening to the family. The client would need to request restriction of visits, and the client is the person who needs the support, then the family. Right now is not the right time to discuss stages of dying; addressing breathing problems is the priority

There is a predominant pattern of variations that occur during the male sexual response. Which of the following occurs during the orgasm phase? a) Expulsive contractions of the urethra. b) Rapid loss of vasocongestion. c) Thickening of the the scrotal skin. d) Thickening of the penis at the coronal ridge.

Expulsive contractions of the urethra. Correct Explanation: Expulsive contractions of the entire length of the urethra occur during orgasm. Rapid loss of vasocongestion is seen in the resolution phase, which is the fourth and final phase immediately after orgasm. Thickening of the scrotal skin occurs during the excitement phase. During the plateau phase, the penis circumference at the coronal ridge thickens

A nurse is developing a nursing diagnosis for a client. Which information should she include? a) Factors influencing the client's problem b) Nursing history c) Expected outcomes d) Actions to achieve goals

Factors influencing the client's problem Correct Explanation: A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.

When bandaging a client's ankle, the nurse should use which technique? a) Figure-eight b) Circular c) Recurrent d) Spiral reverse

Figure-eight Correct Explanation: The nurse uses a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast.

A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do? a) Give the nurse the lightest workload on the unit. b) Find another nurse to cover the unit and send the nurse back to the surgery unit. c) Tell the nurse to buddy up with someone else and do the best that the nurse can do. d) Tell the nurse that as an RN, the nurse should be competent to work in any area.

Find another nurse to cover the unit and send the nurse back to the surgery unit. Correct Explanation: Nurses are accountable for their practice and must recognize the limitations of their own competency. To the extent possible, the nurse manager must ensure nurses working on their units have the required knowledge, skills, and competencies. The other options are incorrect because they do not ensure that the clients are receiving care from the most competent nurse

The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which data indicate that nursing interventions of monitoring and teaching have been effective? a) Eighty percent of the clients reported that they are taking their medications. b) Ninety percent of clients have not gained weight. c) Seventy-five percent of the clients viewed the educational DVD. d) Five percent of the clients required hospitalization in the last 90 days.

Five percent of the clients required hospitalization in the last 90 days. Explanation: The goals of managing clients outside of the hospital are for the clients to maintain health and prevent readmission; thus interventions, such as monitoring and teaching, appear to have contributed to the low readmission rate in this group of clients. Although it is important that clients do not gain weight, view educational material, and continue to take their medication, the primary indicator of effectiveness of the program is the lack of rehospitalization.

Two days after a right total knee replacement, a client rates his right-knee pain as 9 on a 10-point pain scale. A physician orders hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain. When a nurse notifies the physician of the client's pain, the physician states that one hydrocodone/APAP tablet should be sufficient and refuses to order anything stronger for pain. Which measure should the nurse select to act as an advocate for the client? a) Give the client 2 hydrocodone/APAP tablets every 4 hours. b) Give the client 1 hydrocodone/APAP tablet every 3 hours. c) Document that the physician was notified of the client's pain and continue to administer hydrocodone/APAP as ordered. d) Follow the chain of command to obtain adequate pain relief for the client.

Follow the chain of command to obtain adequate pain relief for the client. Correct Explanation: Clients must receive adequate pain relief. Allowing a client to experience a pain score of 9 out of 10 is unacceptable nursing practice. Acting as a client advocate requires a nurse to be assertive, even if this means confronting a physician. If the physician doesn't give an order for adequate pain relief, the nurse should follow the chain of command to report the physician's inaction and obtain adequate pain relief for the client. A nurse may not adjust medication frequency or dosage without a physician's order.

Which plane divides the body longitudinally into anterior and posterior regions? a) Frontal plane b) Midsagittal plane c) Transverse plane d) Sagittal plane

Frontal plane Correct Explanation: A frontal or coronal plane, which runs longitudinally at a right angle to a sagittal plane, divides the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions

Which plane divides the body longitudinally into anterior and posterior regions? a) Midsagittal plane b) Frontal plane c) Transverse plane d) Sagittal plane

Frontal plane Explanation: A frontal or coronal plane, which runs longitudinally at a right angle to a sagittal plane, divides the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery. What should the nurse do? a) Reassure the client that her children will be fine and she should stop worrying. b) Contact the relative to determine their capacity to be an adequate care provider. c) Encourage the client to call the children to make sure they are doing well. d) Gather more information about the client's feelings about the childcare arrangements.

Gather more information about the client's feelings about the childcare arrangements. Correct Explanation: The health history is conducted to ascertain a client's state of wellness or illness. A personal dialogue between a client and a nurse is conducted to obtain information. To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the client. The therapeutic communication must be adapted to the responses, problems, and needs of the client. Reassurance and the remaining options do not demonstrate that the nurse is genuinely interested in the client's needs

An elderly client with primary degenerative dementia is slow in following simple directions and is indecisive selecting clothes to be worn for the day. What is the best approach for the nurse to take? a) Allow the client to select from the outfits and minimize other distractions in the environment. b) Pick an outfit and assist with dressing because the client is too distracted to complete this activity without help. c) Give the client the opportunity to select from two outfits and cue follow-through instructions. d) Time limit the indecision and let the client know that activities of daily living need to be completed faster.

Give the client the opportunity to select from two outfits and cue follow-through instructions. Correct Explanation: Dementia results in an impairment of abstract thinking and in decision making. As much as possible, it is important to give simple choices and to cue the client to follow through because of the memory lapses. Giving too many choices makes it difficult to make a decision. Giving no choice takes away any decision making opportunities

A nurse is reluctant to provide care at an accident scene. Which of the following legal definitions is true regarding the provision of nursing care? a) Scope of practice involves general guidelines that define nursing. b) Malpractice is failure to perform professional duties that result in client injury. c) Good Samaritan laws are designed to protect the caregiver in emergency situations. d) Negligence is intentional failure to act responsibly or deliberate omission of a professional act.

Good Samaritan laws are designed to protect the caregiver in emergency situations. Explanation: Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection. Failure to stop would constitute an issue. Malpractice involves the failure to perform professional duties; it may involve omissions of important care measures or performing care measures that are not appropriate in the situation. Negligence is failure to act professionally. Scope of practice includes specific guidelines of professional conduct

A charge nurse assesses a group of staff nurses as competent individually but ineffective and nonproductive as a team. How should the charge nurse address the staff nurses about her concerns? a) Incorporate the staff nurses in decision making. b) Increase staffing to prevent fatigue from overwork and understaffing. c) Ask the staff nurses if they feel unhappiness about the current leadership. d) Have the staff nurses express their feelings and emotions.

Have the staff nurses express their feelings and emotions. Explanation: The most common reason for lack of productivity in a group of competent nurses is inadequate communication or unexpressed feelings and emotions. Unhappiness about leadership, fatigue from overwork and understaffing, and failure to incorporate staff in decision making could contribute to the problematic situation, but they're less likely to be the cause of the problem

The nurse is completing a sexual history on a client. The client reports a history of having a sexually transmitted infection (STI) which lies dormant in the body and can reoccur, but does not remember the name. Which STI matches the client's description? a) Chlamydia b) Herpes infection c) Syphilis d) Gonorrhea

Herpes infection Correct Explanation: The nurse is most accurate to identify the herpes infection as the virus can remain dormant in the ganglia of the nerves. Symptoms are usually more severe with the initial outbreak. Subsequent episodes are usually shorter and less intense. The other infections do not have the same characteristics and, if identified, will be documented in the history.

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment best determines an expected finding? a) High pitched gurgling noises in four abdominal quadrants b) Sounds heard only in bilateral lower quadrants c) High pitched, tinkling bowel sounds d) Two to three bowel sounds per minute

High pitched gurgling noises in four abdominal quadrants Correct Explanation: High-pitched gurgles heard in four abdominal quadrants are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction

The nurse is preparing for the admission of a client on a stretcher. In what position should the nurse place the bed? a) High Fowler's position. b) Highest position. c) Middle position. d) Lowest position.

Highest position. Explanation: The nurse would place the bed in the highest position if the client will arrive on a stretcher. For ambulatory clients, the bed should be in the lowest position. The High Fowler's position is often used for clients with respiratory difficulties.

An elderly client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client? a) Hyperthermia b) Activity intolerance c) Disturbed thought processes d) Impaired physical mobility

Hyperthermia Explanation: With age, the body's ability to regulate temperature diminishes and the number of sebaceous and sweat glands decreases. These changes put the elderly client at risk for Hyperthermia. Because hyperthermia can be life-threatening, this nursing diagnosis takes highest priority. If Activity intolerance, Disturbed thought processes, and Impaired physical mobility are relevant, the nurse should assign them lower priority when planning this client's care

A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply. a) Bivalving the cast on both sides. b) Maintain the leg elevated above the level of the heart. c) Monitor distal pulses of the affected extremity d) Apply warm compresses to the casted leg. e) Administer anticoagulation per healthcare provider's order.

Monitor distal pulses of the affected extremity • Maintain the leg elevated above the level of the heart. • Administer anticoagulation per healthcare provider's order. Explanation: The nurse would monitor the tightness of the cast by assessing the distal pulses and tightness of the cast. Edema can cause the cast to become tight and lead to compartment syndrome. Unless contraindicated, the leg would be elevated above the heart in order to increase venous return and decrease edema. Prophylactic anticoagulation will decrease the risk of clot formation. The nurse would apply cool compresses not warm. It is not within the nurse's scope of practice to cut the cast or bivalve the cast.

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? a) Monitor vital signs every 4 hours. b) Measure blood urea nitrogen and serum creatinine levels. c) Measure intake and output. d) Monitor the appearance, size, and number of stools.

Monitor the appearance, size, and number of stools. Explanation: A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't indicate the effectiveness of nutritional therapy

Which nursing intervention is appropriate for a client with an arm restraint? a) Positioning the restrained arm in full extension b) Tying the restraint to the side rail c) Monitoring circulatory status every 2 hours d) Applying the restraint loosely to prevent pressure on the skin

Monitoring circulatory status every 2 hours Correct Explanation: A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment? a) Notify the supervisor that this is a relative but the relationship will not be a conflict. b) Ask the aunt if she would like the nurse to take care of her while in the hospital. c) Accept the assignment and not disclose the relationship with the client. d) Notify the supervisor and provide care until another nurse can be assigned to the client.

Notify the supervisor and provide care until another nurse can be assigned to the client. Correct Explanation: The nurse should notify the supervisor of the relationship with the client and ask to be reassigned. If no other nurse is immediately available, the nurse should provide the necessary care until another nurse can assume responsibility for the aunt's care. The other answers are incorrect because the nurse may not be able to ensure that the therapeutic nurse-client relationship can be maintained when caring for a family member

Which of the following patient statements most clearly suggests the potential nursing diagnosis of Spiritual Anxiety? a) "I guess I should have taken a lot more time to go to church when I was younger." b) "Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." c) "I always tried to do the right thing, so I don't understand why I have to suffer so much now." d) "I've never been a religious man, and all these Catholic crosses and pictures in the hospital make me a bit uncomfortable."

Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." Explanation: Worry about one's spiritual condition is indicative of Spiritual Anxiety. Unfamiliarity with the religious character of a care setting suggests Spiritual Alienation, while questions of suffering often indicate Spiritual Pain or Spiritual Despair. Regrets over previous religious or spiritual apathy may suggest a nursing diagnosis of Spiritual Guilt.

A North American nurse is caring for a Chinese client. How can the nurse better understand the client's cultural values and beliefs? a) Inquiry about behavior patterns. b) Careful observation. c) Long-term contact. d) Nursing and medical journals.

Nursing and medical journals. Explanation: The nurse can use nursing and medical journals to understand about the client's cultural values and beliefs. Long-term contact, with careful observation and inquiry about patterns in behavior, are approaches of anthropologists and may take too long for most nurses

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of: a) Electronic medical records. b) Telemedicine. c) Nursing informatics. d) Computerized documentation.

Nursing informatics. Correct Explanation: Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. A specific application of nursing informatics is the use of PDAs in the clinical setting. The devices are less likely to be used to perform documentation or to constitute client records. Telemedicine involves the remote provision of care

A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because: a) Nursing practice involves numerous interactions between laws and individual values. b) Nurses are highly vulnerable to criminal and civil prosecution in the course of their work. c) Nurses are responsible for carrying out actions that have been ordered by other individuals. d) Nurses interact with clients and families from diverse cultural and religious backgrounds.

Nursing practice involves numerous interactions between laws and individual values. Explanation: A code of ethics is necessary to guide nurses' conduct, especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics.

A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family? a) Demonstrate to the family that pureed foods or liquids result in coughing. This signifies the importance of the need for a feeding tube. b) Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. c) Because of limited mobility, the client is susceptible to developing pneumonia. Extra nutrients are necessary to strengthen the immune system and promote recovery. d) Tube feedings are less invasive than total parenteral nutrition; either one can meet hydration and nutritional needs.

Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. Correct Explanation: A swallowing assessment will test whether there is complete closure of the epiglottis during swallowing. Incomplete closure indicates that there is not protection of the trachea during oral ingestion of food or fluids. This will necessitate insertion of a nasogastric tube and initiating tube feedings. Tube feedings are less invasive, but this does not answer the underlying basis for insertion of the feeding tube. Demonstrating to the family that the client will choke presents a hazard and is inappropriate when swallowing impairment has been diagnosed. Limited mobility and being susceptible to pneumonia does not answer the underlying reason for the feeding tube.

While performing an assessment of a 75-year-old female in the emergency department, a nurse notes many bruises in various stages of healing on the client's body. After documenting the locations of the bruises in the medical record, which step should the nurse take immediately? a) Follow the facility's policy and procedures for reporting elder abuse. b) Obtain more information from the client about the nurse's findings. c) Notify the nursing supervisor. d) Notify the physician.

Obtain more information from the client about the nurse's findings. Explanation: The nurse should try to obtain more information from the client to complete the assessment. Without supporting information, she shouldn't assume the bruises indicate abuse, and she shouldn't notify her nursing supervisor until she has obtained additional facts. She should, however, inform the physician so he can examine the client. She should follow the facility's policy and procedure for reporting abuse. The nurse should make a report if, after the assessment, she has a strong suspicion that abuse is the cause

In many institutions, which of the following telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner? a) Orders for respiratory treatments. b) Orders for diagnostic studies. c) Orders for dietary changes. d) Orders for antibiotics.

Orders for antibiotics. Correct Explanation: Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours

A client has a nursing diagnosis of fluid volume deficit. Which of the following nursing assessment findings would support this diagnosis? a) Leathery, pliable skin b) Pretibial pitting edema c) Pedal pulses of 4+ d) Orthostatic blood pressure changes

Orthostatic blood pressure changes Explanation: Fluid volume deficit is characterized by hypotension, tachycardia, increased body temperature, and weakness. Leathery, pliable skin may not demonstrate fluid deficit; it may reflect diabetes. Pitting edema and pedal pulses of 4+ demonstrate localized edema and potential fluid excess

A nurse cares for a client who believes in Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior? a) Unhygienic habits. b) Consumption of dirty food. c) Poor worship of God. d) Past and current life actions.

Past and current life actions. Correct Explanation: According to Hinduism, illness is the result of past and current life actions. The right hand is seen as holy, and eating and intervention need to be done with the right hand to promote clean healing. The spiritual health belief in Hinduism is not that illness is from consumption of dirty food, unhygienic habits, or poor worship of God

A 56-year-old male client is experiencing withdrawal from alcohol and placing himself at risk for falls by repeatedly attempting to scale his bedrails. Benzodiazepines have failed to alleviate his agitation and the nurse is considering obtaining an order for physical restraints to ensure his safety. The nurse should recognize that this measure may constitute: a) Harm. b) Advocacy. c) Deception. d) Paternalism.

Paternalism. Explanation: Paternalism involves the violation of a client's autonomy to maximize good or minimize harm, a situation that requires careful consideration in light of ethical principles. Deception is unlikely and the risk for harm is likely decreased by the use of restraints. Advocacy is the protection and support of another's rights.

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? a) People of Asian descent prefer some distance between themselves and others. b) People of Asian descent prefer direct eye contact when communicating. c) People of Asian descent commonly stand close to one another when talking. d) People of Asian descent touch one another when sitting next to a familiar person.

People of Asian descent prefer some distance between themselves and others. Correct Explanation: 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

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? a) Perform thorough hand washing before and after touching any child in the day care center. b) Restrict the infected children from returning for 48 hours after treatment. c) Close the day care center for 1 week to control the outbreak. d) Set up a conference with the parents of each child to explain the situation carefully

Perform thorough hand washing before and after touching any child in the day care center. Correct Explanation: Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection

Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. a) Documenting a client's oral intake b) Taking a client's vital signs c) Evaluating a client's response to a blood pressure medication d) Assessing a client's pain e) Performing a blood glucose check

Performing a blood glucose check • Documenting a client's oral intake • Taking a client's vital signs Correct Explanation: Registered nurses are responsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed)

The nursing staff on the antepartal unit has leuprolide acetate and medroxyprogesterone acetate in the pharmacy for their clients. The nursing staff observed that the vials are similar in size and shape and could be confused. In order to promote client safety, the nursing staff should take which actions? Select all that apply. a) Leave repositioning of drugs to pharmacy staff to resolve. b) Collaborate with pharmacy staff to develop a location that works well for both groups. c) Petition the pharmacy to relocate one drug away from the other product. d) Communicate concerns, measures to remediate, and final decisions to all staff. e) Move the drugs to a new position within the medication administration system during the night shift.

Petition the pharmacy to relocate one drug away from the other product. • Communicate concerns, measures to remediate, and final decisions to all staff. • Collaborate with pharmacy staff to develop a location that works well for both groups. Explanation: Notifying the pharmacy of the nursing concerns is an appropriate first action. The nursing staff should work cooperatively with the pharmacy to develop a system that works well for both nursing and pharmacy. Constant communication with all nursing staff during the quality improvement process is integral to the final approval process of both groups. Moving the drugs to a new position within the medication system during an off shift may create errors, as medications are inserted into the system in a certain position. Leaving the decisions to the pharmacy staff eliminates the input provided by nursing, a vital link between medication and the client.

When providing oral hygiene for an unconscious client, the nurse must perform which action? a) Place the client in a side-lying position. b) Clean the client's tongue with gloved fingers. c) Swab the client's lips, teeth, and gums with lemon glycerin. d) Place the client in semi-Fowler's position.

Place the client in a side-lying position. Correct Explanation: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness? a) Pressing firmly with one hand, releasing pressure while maintaining fingertip contact with the skin, and noting increased tenderness on release b) Using deep ballottement, noting any tenderness over an area c) Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any increased tenderness on release d) Using light palpation, noting any tenderness over an area

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any increased tenderness on release Correct Explanation: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. She doesn't use light palpation or deep ballottment or maintain fingertip contact with skin to elicit rebound tenderness.

The nurse is teaching a group of high school students about risk-taking behaviors. Which of the following topics would be considered an example of healthy behaviors? a) Responsible drinking patterns b) Preventative vaccinations c) Motor vehicle accidents d) Effects of cigarette smoking

Preventative vaccinations Correct Explanation: Preventative vaccinations are not associated with a risk-taking behavior. Vaccinations are used as vehicles to prevent communicable diseases rather than living dangerously. The other choices are all associated with risk-taking behaviors: smoking, drinking, and motor vehicle accidents. These are especially important to discuss with young adults.

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation? a) Self-esteem b) Age c) Self-actualization d) Previous coping skills

Previous coping skills Correct Explanation: Coping is the process through which a person uses cognitive and noncognitive resources to resolve problems. Cognitive responses result from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Previous coping skills are cognitive in nature and include the thought and learning necessary to identify the source of stress in a current crisis situation. Therefore, such coping skills would have the most influence on the outcome of a crisis situation. Previous coping skills could determine whether age has a positive or negative impact during a crisis. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis, as well as arriving at a better solution to the problem. The involved person's correct or incorrect perception of the problem could result in a positive or negative outcome

A nurse is administering a prescribed dose of an injection to a middle-aged client with Bell's palsy. What are the sources of fulfillment in the middle-years of an adult client's life? a) Personal experiences b) Advanced study c) Sense of faith d) Productive activity

Productive activity Explanation: The middle years are fulfilled through productive activity—in Erikson's term, generativity. This time is of growth and renewed questioning, in some ways very similar to adolescence. For young adults, their beliefs and attitudes change due to some situations such as advanced study or education or new religious affiliations possibly intertwined with achieving intimate relationships, choosing careers, and starting families. The challenge during this stage is to establish one's own sense of faith and commitment based on personal experience and reflection on meaning in life

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? a) Provides the client with in-depth knowledge about the treatment options available. b) Helps the client refuse treatment that he or she does not wish to undergo. c) Protects the client's right to self-determination in health care decision making. d) Helps the client to make a living will regarding future health care required.

Protects the client's right to self-determination in health care decision making. Correct Explanation: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which of the following actions should the nurse take to best ensure the safety of the client while complying with policy? a) Instruct the client on use of the call bell. b) Provide a bed that is low to the floor. c) Raise all side rails while the client is in bed. d) Have a family member stay with the client.

Provide a bed that is low to the floor. Explanation: Providing a bed that is low to the floor complies with the least restraint policy and prevents falls from the bed. Raising all side rails on the bed would be considered excessive restraint and could contribute to greater risk of injury if the client tried to climb out of bed. The other options do not fully ensure the safety of the client.

A client on heparin for a deep vein thrombosis reports an aching pain in the back and finds it difficult to get comfortable when lying in that position. The client refuses to take any medications for pain. What actions would the nurse take to alleviate the back pain? a) Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain. b) Reinforce the importance of changing positions and the possibility of pressure ulcer formation. c) Suggest alternating side-lying positions to lessen the back pain. d) Encourage the client to take the medications to provide optimal rest.

Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain. Correct Explanation: It is important to respect the client's decision and to try other supportive measures to alleviate the pain.

During hospitalization for a suicide attempt, a client informs the nurse that she does not want to return to work because her boss expects sexual favors each week before he pays her. The client informs the nurse that she needs the job but is embarrassed that she performs these favors. The nurse informs the client that this is illegal behavior called: a) Fetishism. b) Hostile environment harassment. c) Environmental harassment. d) Quid pro quo harassment.

Quid pro quo harassment. Explanation: Quid pro quo means that something is given or withheld in exchange for something else. It generally occurs when a person in a position of authority offers either direct or indirect reward or punishment based on the granting of sexual favors. Environmental harassment and hostile environment harassment are the same situation and occur when workplace behaviors of a sexual nature create a hostile, intimidating environment that interferes with a person's work performance. Fetishism is sexual arousal with the aid of an inanimate object not generally associated with sexual activity

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next? a) Discard the residual, and subtract the residual amount from the feeding. b) Administer an amount of water equivalent to the feeding. c) Hold the feeding, and recheck the residual in 4 hours. d) Return the residual and begin the feeding.

Return the residual and begin the feeding. Explanation: The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client`

A nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test? a) Weber's test b) Rinne test c) Whispered voice test d) Watch tick test

Rinne test Explanation: The Rinne test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low-pitched sounds, and the watch tick test assesses high-pitched sounds. Both tests assess gross hearing. Weber's test evaluates bone conduction

Which is the correct technique when the nurse is applying an elastic bandage to a leg? a) Increase tension with each successive turn of the bandage. b) Secure the bandage with clips over the area of the inner thigh. c) Overlap each layer twice when wrapping. d) Start at the distal end of the extremity and move toward the trunk.

Start at the distal end of the extremity and move toward the trunk. Correct Explanation: 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.

The nurse notes that which statement concerning informed consent is true? a) Mentally incompetent clients may legally give informed consent only if they are hospitalized under a mental health regulatory law. b) The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each. c) The professional nurse and physician must each obtain informed consent because the practice of medicine and of nursing are two distinct entities. d) Minors may give informed consent to all medical and nursing procedures without consent of the parent(s).

The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each. Correct Explanation: Before giving informed consent, the physician performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. A professional nurse involved in the informed consent process witnesses the consent and doesn't actually obtain the consent. The physician is responsible for obtaining consent. Only a minor who is married or emancipated may give informed consent. A client must be mentally competent to legally give informed consent for procedures

The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of which of the following? Select all that apply. a) Freedom from coercion b) Caregiver preference and opinion c) Verification from next of kin d) Discussion of pertinent information e) The client's agreement to the plan of care

The client's agreement to the plan of care • Freedom from coercion • Discussion of pertinent information Correct Explanation: Discussion of pertinent information, the client's agreement to the plan of care, and freedom from coercion are important factors in informed consent. Caregiver preference and opinion could be perceived as coercion. Informed consent does not require verification from next of kin

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved? a) The entry should include clearer descriptions of the client's mood and behavior. b) The entry should specify the subsequent interventions that were performed. c) The entry should avoid mentioning cognitive or psychosocial issues. d) The entry should list the specific reasons that the client was upset.

The entry should include clearer descriptions of the client's mood and behavior. Correct Explanation: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing her/his hands before entering a client's room. Which of the following observations would alert the nurse educator to the need for further education? a) The nurse keeps her hands lower than her elbows while washing. b) The nurse uses at least 3 to 5 mL of liquid soap. c) The nurse dries from her finger tips down toward her elbows. d) The nurse dries from her forearms up toward her fingers.

The nurse dries from her forearms up toward her fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

When providing care on an Indian reservation (First Nations reserve), a nurse has prioritized assessments for type 2 diabetes mellitus and fetal alcohol syndrome. How should the nurse's practice be best understood? a) The nurse is correct in assessing for health problems that have a higher incidence and prevalence among this population. b) The nurse is performing cultural imposition of the majority of American (Canadian) culture and the accompanying beliefs around diabetes and alcohol use. c) The nurse should seek specific permission from each client before proceeding with these assessments. d) The nurse is stereotyping American Indians (First Nations people) as leading unhealthy lifestyles and abusing alcohol.

The nurse is correct in assessing for health problems that have a higher incidence and prevalence among this population. Correct Explanation: Because diabetes and fetal alcohol syndrome are known to have a higher incidence and prevalence among American Indians (First Nations people), the nurse is justified in reflecting this objective reality during health assessment. This action is rooted in epidemiology, not the inaccurate generalizations of stereotyping. Because the consequences of both problems are significant and objective, the nurse is not guilty of cultural imposition and specific permission for these assessments is not likely necessary

Which statement best explains why the nurse should acknowledge differences between his or her culture and the client's culture? a) The nurse can alter his or her beliefs to match the client's. b) The nurse can anticipate the client's response to nursing care. c) The nurse can determine which cultural groups will be noncompliant with their health care. d) The nurse may hold values that could influence the care of the client.

The nurse may hold values that could influence the care of the client. Correct Explanation: In order to avoid ethnocentric behavior toward the client, it is important that nurses acknowledge what their cultural beliefs are and be careful not to impose them on the clients they care for because this could influence the quality of care. It is stereotypical for nurses to assume that they can determine which cultural groups will be noncompliant. It is stereotypical for nurses to anticipate the client's response to care based on the client's culture. Nurses need to be aware of their beliefs and not alter them to match the client's culture.

What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor? a) The nurse is aware that adverse reports are not confidential material, so only documentation in the chart should be completed. b) The nurse must file an incident or adverse event report. c) The nurse must communicate the event to the charge nurse, who will document the fall in an adverse reporting system. d) The nurse must chart about the incident and communicate in a report about the event.

The nurse must file an incident or adverse event report. Correct Explanation: Nurses who witnessed the event are responsible for entering the information. Adverse reporting is a mechanism to find persistent problems; it is confidential and nonpunitive.

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind? a) The current reimbursement system recognizes the family's nontechnical value priorities. b) Family caregivers are always perceived to be supportive of good care. c) Nurses should avoid asking the family caregivers to conduct the skilled task. d) The nurse needs to be creative in integrating the technical and relational aspects of care.

The nurse needs to be creative in integrating the technical and relational aspects of care. Explanation: The nurse needs to be creative in integrating the technical and relational aspects of care. The current reimbursement system does not recognize the family's nontechnical value priorities. Nurses are expected to educate the family caregivers to conduct the skilled task where possible. In this case, the nurse can teach the family caregivers to inject insulin. Family caregivers can be perceived to be nonsupportive of good care if the families do not follow through.

A dying patient requests that the nurse pray with him. The nurse is not accustomed to praying aloud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this patient? a) The nurse should inform the patient that he or she will pray for but not with the patient. b) The nurse should defer the patient's request to pray. c) The nurse should select a formal prayer or Bible passage to use to pray aloud. d) The nurse should ask the patient's roommate to pray with the patient.

The nurse should select a formal prayer or Bible passage to use to pray aloud. Correct Explanation: A nurse unaccustomed to praying aloud or in public may find it helpful to have a Bible passage or formal prayer readily available for praying. If the nurse is not comfortable praying with the patient, he or she should call the hospital chaplain or find another individual who is comfortable

Which of the following factors should be the primary factor in a nurse's decision whether to pray with a patient? a) The availability of a hospital chaplain or other spiritual counselor. b) The patient's openness to being prayed for. c) The nature and course of the patient's current diagnosis. d) The nurse's familiarity with the prayer traditions of different faiths.

The patient's openness to being prayed for. Correct Explanation: Many factors influence the nurse's decision to pray with a patient. Central among these, however, is the question of whether the patient is open to this possibility. This factor is more important than the nurse's familiarity with specific prayer traditions, the patient's medical condition, or the presence or absence of a chaplain

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs? a) "There is nothing physically wrong with you. You need to stop breathing so rapidly." b) "It must have been a frightening experience to be in an accident." c) "I'll stay with you in case you would like to share your feelings with me." d) "Accidents can result in all kinds of feelings. It must have been scary."

There is nothing physically wrong with you. You need to stop breathing so rapidly." Correct Explanation: In this response, the nurse is addressing the client's hyperventilation and other somatic symptoms, rather than the client's feelings about the accident. The other options address the client feelings about the accident.

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record? a) To transmit health records between insurance companies. b) To inform family and others concerned about the client's care. c) To release the entire health record for research. d) To investigate the quality of care in the agency.

To investigate the quality of care in the agency. Correct Explanation: Medical records may occasionally be used to investigate the quality of care in the agency. A medical record is not used to transmit health records between insurance companies, to inform family and others concerned about the client's care, or to release the entire health record for research, as these actions would jeopardize the individual's right to privacy.

A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings? a) To reduce or prevent edema of the legs and feet b) To maintain warmth in the legs c) To decrease arterial blood circulation to the legs and feet d) To decrease venous blood circulation from the legs and feet

To reduce or prevent edema of the legs and feet Correct Explanation: Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing — not decreasing — arterial and venous blood circulation to the legs and feet. They don't maintain warmth in the legs. Blankets can be used for this purpose.

An African-American (Black) client is brought to the emergency department after sustaining injury in a vehicle accident. The client is bleeding profusely from the wounded leg. In which of the following areas should the nurse check for pallor in the client? a) Tongue. b) Face. c) Abdomen. d) Hands.

Tongue. Explanation: In the African-American (Black) client, the nurse should check the tongue for pallor. Face, hands, and abdomen are not appropriate places to check for pallor because these areas have heavy pigmentation

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? a) Applying an antibiotic cream to the area three times per day b) Massaging the area with an astringent every 2 hours c) Using a povidone-iodine wash on the ulceration three times per day d) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary

Using normal saline solution to clean the ulcer and applying a protective dressing as necessary Correct Explanation: The nurse may wash the area with normal saline solution and apply a protective dressing. These interventions will protect the area and are within the nurse's scope of practice. A nurse must obtain a physician's order to use a povidone-iodine wash or an antibiotic cream. Massaging with an astringent can further damage the skin

A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions? a) Pustules b) Vesicles c) Papules d) Plaque

Vesicles Explanation: Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? a) Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. b) Review and revise the way client education is conducted in the surgeons' office. c) Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. d) Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints.

Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. Explanation: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.

A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order? a) Obtain confirmation of the order from a physician or nurse practitioner present on the unit. b) Write out the order, the physician's name, the nurse's name, and the name of a witness. c) Record the order verbatim in the client's charts and follow it with the nurse's printed name and signature alone. d) Write "T.O." after the order and write out the physician's and nurse's names.

Write "T.O." after the order and write out the physician's and nurse's names. Correct Explanation: When receiving telephone orders, the nurse should record the orders in the client's medical record, read the order back to the ordering practitioner, date and note the time the orders were issued, record T.O. (telephone orders) and the full name and title of the physician or nurse practitioner who issued the orders, and then sign the orders with name and title. It is unnecessary to obtain a confirmation from another practitioner or to have the order witnessed.

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? a) an 80-year-old who has a compound fracture of the arm b) a 10-year-old with a laceration on his leg c) a 20-year-old who is unresponsive and has a high injury to his spinal cord d) a 25-year-old with a sucking chest wound

a 25-year-old with a sucking chest wound Explanation: During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment? a) a 3-year-old with a fever of 100° F (37.8° C), a barky cough, and mild intercostal retractions b) a 4-year-old with a fever of 101° F (38.3° C), a hoarse cough, inspiratory stridor, and restlessness c) a 13-year-old with a fever of 104° F (40° C), chills, and a cough with thick yellow secretions d) a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling Explanation: This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client? a) an 84-year-old client with diabetes admitted with new-onset confusion who reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock b) a 48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter c) a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance d) a 27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; no significant medical history, smokes two packs of cigarettes per day; may be up independently; and has steady gait

a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance Explanation: Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client no. 1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35 points). Client no. 4 is at risk due to his IV access only (20 points)

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require: a) monitoring of arterial oxygen saturation (SaO2). b) arterial blood gas (ABG) studies. c) chest auscultation. d) a chest X-ray.

a chest X-ray. Explanation: Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently

Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first? a) a primigravida at 17 weeks' gestation who reports not feeling fetal movement at this point in her pregnancy b) a client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day c) a client at 13 weeks' gestation who is experiencing nausea and vomiting three times a day with + 1 ketones in her urine d) a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain

a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain Correct Explanation: A preeclamptic client with +3 proteinuria and epigastric pain is at risk for seizing, which would jeopardize the mother and the fetus. Thus, this client would be the highest priority. The client at 13 weeks' gestation with nausea and vomiting is a concern because the presence of ketones indicates that her body does not have glucose to break down. However, this situation is a lower priority than the preeclamptic client or the insulin-dependent diabetic. The insulin-dependent diabetic is a high priority; however, fetal movement indicates that the fetus is alive but may be ill. As few as four fetal movements in 12 hours can be considered normal. (The client may need additional testing to further evaluate fetal well-being.) The client who is at 17 weeks' gestation may be too early in her pregnancy to experience fetal movement and would be the last person to be seen.

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." The nurse should: a) tell the client that it would be best if she did not see the baby. b) allow the client to see the baby through the nursery window. c) contact the primary care provider for advice related to the client's visitation. d) allow the client to see and hold the baby for as long as she desires.

allow the client to see and hold the baby for as long as she desires. Correct Explanation: The nurse should allow the client to see and hold the baby for as long as she desires. Such activities provide memories for the mother and assist in the grieving process. There is a possibility that the client may change her mind about the adoption. If the client changes her mind about the adoption, the nurse should accept the client's decision and notify the primary care provider and social worker. Telling the client that it would be best if she did not see the baby is imposing the nurse's value system on the client. Allowing the client to see the baby through the nursery window is inappropriate because the client should be allowed to touch and hold the baby. Contacting the primary care provider for advice related to the client's visitation is not necessary.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection? a) a 6-year-old with a simple fracture of the femur b) an 18-year-old with diabetes mellitus c) an 86-year-old with burns from using a heating pad d) a 42-year-old with a recent, uncomplicated appendectomy

an 86-year-old with burns from using a heating pad Correct Explanation: The very young and the elderly are more susceptible to infection. An elderly client with a break in skin integrity, such as the 86-year-old with a burn, is at an increased risk for infection. The 6-year-old does not have a compound fracture (protruding through the skin) and is not at high risk for infection. A client with an appendectomy is at risk for infection of the surgical site but not as high a risk as the client with burns. While a client with diabetes is at risk for infection, this adolescent is not at high risk at this time.

Which client would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP) for morning care? a) an elderly client experiencing chest pain due to suspected pulmonary embolus b) an elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea c) a middle-aged client who had a laryngectomy 2 days earlier d) a young client receiving chemotherapy for Hodgkin's disease

an elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea Correct Explanation: The most appropriate client to assign to a UAP is the elderly client with COPD and mild dyspnea because of the relative stability of the client's chronic condition.

The nurse receives report on the assigned clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving report? a) an elderly client with pneumonia who is exhibiting periods of confusion b) a client who is scheduled for an abdominal perineal resection in the morning and is visiting with the family c) a client receiving total parenteral nutrition (TPN) via a central line with 400 mL remaining in the IV fluid bottle d) a young client with chest tubes placed for treatment of a pneumothorax who is resting comfortably

an elderly client with pneumonia who is exhibiting periods of confusion Correct Explanation: Because of the elderly client's diagnosis of pneumonia and periods of confusion, there is the potential for client injury and decreased levels of oxygenation. The nurse should assess this client first. The client going to surgery does not require the nurse's attention right away. The TPN solution is infusing and will not require changing immediately. The client with chest tubes is not in imminent danger; the nurse can continue to assess this client but not as a priority.

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated? a) applying an external fetal monitor and completing a physical assessment b) obtaining a fundal height assessment on the client c) applying an external fetal monitor and performing a sterile vaginal examination d) obtaining fundal height and performing a sterile vaginal examination

applying an external fetal monitor and completing a physical assessment Explanation: Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.

When obtaining a client's history, the nurse should: a) auscultate for the client's breath sounds. b) palpate the client's abdomen. c) ask questions about the client's reason for seeking care. d) document medication administered.

ask questions about the client's reason for seeking care. Correct Explanation: When obtaining a client's history, the nurse gathers subjective data by asking questions about the client's reason for seeking care, current health status, and other factors, such as past medical, family, psychosocial, and nutritional history. The nurse performs palpation and auscultation during the physical examination and documents medications administered when implementing the care plan

The client with recurrent depression and suicidal ideation tells the nurse, "I cannot afford this medicine anymore. I know I will be okay without it." The nurse should: a) inform the health care provider (HCP) of the client's statement. b) schedule a follow-up appointment in 2 weeks. c) ask the client whether a family member could help. d) ask the social worker to find financial assistance for the client.

ask the social worker to find financial assistance for the client. Explanation: Because the client is in danger of noncompliance with the medication due to financial concerns, the nurse should contact the social worker to assist with locating available resources for the client to ensure continuation of the medication needed for the recurrent illness. The client needs to continue the medications with no interruptions to minimize the chance of decompensation. Although the HCP is the person responsible for prescribing the client's medication, routinely the HCP is not involved in finding financial assistance for the client's medication needs. The client needs the medication at the present time. Scheduling a follow-up appointment in two weeks does not address the immediate concern. The client could stop the medication before being seen and could become severely depressed. A family member's assistance may not be a sufficient or a permanent means of financial help for the client in terms of medication needs

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When coaching the client about the diet, the nurse should first: a) determine the client's knowledge level about cholesterol. b) ask the client to name foods that are high in fat, cholesterol, and salt. c) explain the importance of complying with the diet. d) assess the client's and family's typical food preferences.

assess the client's and family's typical food preferences. Correct Explanation: Before beginning dietary instructions and interventions, the nurse must first assess the client's and family's food preferences, such as pattern of food intake, lifestyle, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base

When preparing discharge instructions for a client after an abdominal hysterectomy, the nurse should first: a) call the social worker to evaluate the client. b) have the client watch an educational video. c) assess the client's available social supports. d) read the discharge instructions to the client.

assess the client's available social supports. Correct Explanation: Assessment is the first step in planning client education. Assessing social support resources is a key aspect of discharge planning that begins when the client is admitted to the hospital. It is imperative to know what assistance and support the client has at home. Assessment includes obtaining data about any family or home responsibilities the client is concerned with during the recovery period. It is within the scope of nursing practice to provide discharge instructions. A social worker is not needed at this time. The nurse should assess the client's needs before determining whether using a video or reading instructions to the client is appropriate

A child with a nut allergy is admitted with a severe reaction for the third time in 3 months. The parent says, "I am having trouble with the food labels." The nurse should first: a) obtain a social service consult. b) notify the health care provider (HCP). c) refer the client to the dietician. d) assess the parent's ability to read.

assess the parent's ability to read. Correct Explanation: Three severe reactions in 3 months indicate a serious problem with adhering to the prevention plan. The nurse should first determine if the parent can actually read the label. The underlying problem may be that the parent is visually impaired or unable to read. The parent's reading level determines what additional support is needed. Referrals to social service or dietary may be indicated, but the nurse does not yet have enough information about the problem. The nurse would communicate with the HCP after assessing the situation to recommend referrals

On the first day after surgery, a client has been breathing room air. Vital signs are normal and O2 saturation is 89%. The nurse should first: a) assist the client to take several deep breaths and cough. b) notify the health care provider (HCP). c) lower the head of the bed. d) administer oxygen by nasal cannula as prescribed at 2L per minute.

assist the client to take several deep breaths and cough. Correct Explanation: Deep breathing and coughing help to increase lung expansion and prevent the accumulation of secretions in postoperative clients. An O2 saturation of 89% is not an unexpected or emergent finding immediately following surgery. Frequent coughing and deep breathing will likely quickly remedy an O2 saturation of 89% but will also effectively help to prevent atelectasis and pneumonia in the remainder of the postoperative period. It is not necessary to notify the HCP prior to intervening with coughing/deep breathing, and it is not appropriate to position this client with the head of bed lower because this would make it more difficult for the client to expectorate secretions. Oxygen may be necessary, but the nurse should assist the client to cough and deep breath first, in an attempt to improve his oxygenation and saturation.

On the first day after surgery, a client has been breathing room air. Vital signs are normal and O2 saturation is 89%. The nurse should first: a) administer oxygen by nasal cannula as prescribed at 2L per minute. b) assist the client to take several deep breaths and cough. c) lower the head of the bed. d) notify the health care provider (HCP).

assist the client to take several deep breaths and cough. Explanation: Deep breathing and coughing help to increase lung expansion and prevent the accumulation of secretions in postoperative clients. An O2 saturation of 89% is not an unexpected or emergent finding immediately following surgery. Frequent coughing and deep breathing will likely quickly remedy an O2 saturation of 89% but will also effectively help to prevent atelectasis and pneumonia in the remainder of the postoperative period. It is not necessary to notify the HCP prior to intervening with coughing/deep breathing, and it is not appropriate to position this client with the head of bed lower because this would make it more difficult for the client to expectorate secretions. Oxygen may be necessary, but the nurse should assist the client to cough and deep breath first, in an attempt to improve his oxygenation and saturation

An elderly client fractured his hip as a result of a fall at home. Because of his extensive cardiac history and chronic obstructive pulmonary disease, surgery isn't an option. The client tells the nurse he doesn't know how he's going to get better. Which response is best? a) "You're doing fine." b) "What is your biggest concern right now?" c) "Give it some time and you'll be OK." d) "You don't believe you're doing well?"

b Open-ended questions allow a client to control what he wants to discuss and help a nurse determine care needs. Telling the client that he's fine or that he just needs more time doesn't encourage him to verbalize his concerns. Reiterating the client's concerns may not encourage him to verbalize his feelings

A client with major depression and psychotic features is admitted involuntarily to the hospital. He will not eat because his "bowels have turned to jelly," which the client states is punishment for his wickedness. The client requests to leave the hospital. The nurse denies the request because commitment papers have been initiated by the health care provider (HCP). The nurse understands this client legally committable based on which criterion? a) being gravely disabled b) risk of harm to self or others c) diagnosis of mental illness d) evidence of psychosis

being gravely disabled Explanation: Criteria for commitment include being gravely disabled and posing a harm to self or others. This client is not threatening to harm himself in the form of suicide or to harm others. The client is gravely disabled because of his inability to care for himself—namely, not eating because of his delusion. Evidence of psychosis or psychotic symptoms or diagnosis of a mental illness alone does not make the client legally eligible for commitment

The client is experiencing parasympathetic responses to pain. What responses should the nurse assess the client for? Select all that apply. a) dilated pupils b) diaphoresis c) increased blood pressure d) bradycardia e) weakness

bradycardia • weakness Explanation: To assess pain properly, the nurse must consider the client's description and the nurse's observations of the client's physical and behavioral responses. Physiologic responses may be sympathetic or parasympathetic in nature. Sympathetic responses are commonly associated with mild to moderate pain and include pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis. Parasympathetic responses are commonly associated with severe, deep pain and include pallor, decreased blood pressure, bradycardia, nausea and vomiting, weakness, dizziness, and loss of consciousness.

A hospitalized client fell on the floor and sustained a small laceration on the hand that required stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit in order to suture the laceration. The nurse should question: a) the cosmetic effect from not having a plastic surgeon do the suturing. b) the client's room as an aseptic environment. c) the intern's ability to suture. d) bupivacaine with epinephrine as the local anesthetic.

bupivacaine with epinephrine as the local anesthetic. Explanation: The nurse should question the use of a local anesthetic agent with epinephrine on the hands or feet because the epinephrine is a vasoconstrictor and can cause ischemia and gangrene of extremities. The nurse should suggest that the intern use bupivacaine without epinephrine as the local anesthetic agent. An intern should be trained in suturing small superficial incisions, and the cosmetic effect should be acceptable. The client's room should be a sufficiently aseptic environment because there is no other client in the room.

Which outcome criterion would be most appropriate for a client with a nursing diagnosis of Ineffective airway clearance? a) Respiratory rate of 28 breaths/minute b) Continued use of oxygen when necessary c) Breath sounds clear on auscultation d) Presence of congestion on X-ray

c The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 28 breaths/minute indicate that the client is still experiencing airway problems.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that: a) only low doses of opioids are safe; higher doses may cause respiratory depression. b) clients with terminal cancer may develop tolerance to opioids. c) a client who can fall asleep isn't in pain. d) pain medication should be given only when a client requests it.

clients with terminal cancer may develop tolerance to opioids. Explanation: Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.

The nurse enters the nondiabetic client's room shortly after a group of health care providers has made rounds. The client asks, "Why did the doctor tell the others that I am not compliant with my diabetes regimen?" The nurse is aware that which ethical principle has been violated? a) confidentiality b) trust c) respect for persons d) fidelity

confidentiality Explanation: All nurses should be aware of the confidential nature of information obtained in daily practice. Discussion of clients with other members of the health care team is often necessary; these discussions should occur in a private area where it is unlikely that the discussion can be overheard. Respect for persons involves treating others in such a way that enables them to make choices. Trust is an essential element in the nurse-client relationship. Fidelity is promise keeping—the duty to be faithful to one's commitments.

The nurse is assessing the lower extremities of the client with peripheral artery disease (PVD). Which findings are expected? Select all that apply. a) moist skin b) hairy legs c) pink skin d) coolness e) mottled skin

coolness • mottled skin Correct Explanation: Reduction of blood flow to a specific area results in decreased oxygen and nutrients. As a result, the skin may appear mottled. The skin will also be cool to the touch. Loss of hair and dry skin are other signs that the nurse may observe in a client with PVD of the lower extremities

To decrease a female client's anxiety about being placed in the lithotomy position for surgery, the nurse should: a) explain in detail what will occur in the operating room. b) pad the stirrups for comfort. c) reassure the client that an all-female surgical team will be present. d) determine what the client is concerned about.

determine what the client is concerned about. Explanation: The nurse should first attempt to find out what the client's concerns are and address them. Providing too much information with details can increase the client's anxiety and does not address specific concerns. Padding the stirrups will provide comfort, but does not address concerns. Having an all-female team may or may not be the source of the client's concerns, and probably is not possible.

A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, "He is doing too much. I told him to let me help, but he will not let me." The nurse says to the wife, "It sounds like you need to feel you can be more helpful to him." In order to make the nonverbal behavior complement the words, the nurse should: a) direct the eyes at the client. b) direct the body and eyes at the wife and client. c) shift the eyes back and forth between the client and wife. d) avoid direct eye contact with the client and wife.

direct the body and eyes at the wife and client. Correct Explanation: Assuming cultural appropriateness of eye contact with the client and his wife, this body language would make the nurse's nonverbal message congruent with the nurse's verbal message and demonstrate empathy. Directing the eyes only toward the client, rather than including the wife, ignores the wife. Avoiding eye contact with the client and wife or shifting the gaze between the client and wife conveys a lack of assurance about the nurse's focus and comment

On the second day after surgery, the nurse assesses an elderly client and finds the following: • blood pressure, 148/92 mm Hg; heart rate, 98 bpm; respirations 32 breaths/min • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • breath sounds are coarse and wet bilaterally with a loose, productive cough • client voided 100 mL very dark, concentrated urine during the last 4 hours • bilateral pitting pedal edema Using the SBAR method to notify the health care provider (HCP) of current assessment findings, the nurse should recommend that the HCP write a prescription for a(n): a) additional fluid intake. b) increased oxygen liter flow rate. c) diuretic medication. d) antihypertensive medication.

diuretic medication. Explanation: The client is experiencing a fluid overload and has vital signs that are outside of normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or administer more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. The nurse should: a) document assessment findings in the client's medical record. b) notify the health care provider (HCP). c) ask another nurse to validate the absence of bowel sounds. d) encourage the client to take more ice chips.

document assessment findings in the client's medical record. Explanation: Bowel sounds are not present until the third or fourth postoperative day; the nurse should document the assessment findings. Too many ice chips may promote abdominal distention, especially if the client is not ambulating in the intermediate postoperative period.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin: a) enhances oxygen transport to tissues. b) restores the inflammatory response. c) reduces edema. d) enhances protein synthesis.

enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? a) every 15 minutes b) every 10 minutes c) every 20 minutes d) every 5 minutes

every 15 minutes Correct Explanation: In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.

A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. The nurse should: a) advise the client that the prolonged neonatal death will be very painful for her. b) contact the client's minister to discuss the client's options related to the pregnancy. c) explore the nurse's own feelings about the issues of anencephaly and organ donation. d) ask the client if her family agrees with her decision.

explore the nurse's own feelings about the issues of anencephaly and organ donation. Correct Explanation: Anencephaly is a neural tube defect that is not compatible with life, although some of these infants live for several days before death occurs. When the client has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain nonjudgmental. The nurse should explore his or her feelings about the issue of anencephaly and organ donation. The nurse should not make judgments about the client's position, nor should the nurse try to persuade the client to terminate the pregnancy. Contacting the client's minister to explore the client's options is not appropriate. As a devout Baptist, the client probably has already discussed the matter with her minister. Telling the client that the neonatal death will be prolonged and painful to her is not helpful. Death may occur very soon after birth. Asking the client about her family's opinion does not help the support the client's decision.

A nurse is assessing a client for the risk of falls. The nurse should obtain: a) gait and balance information. b) the client's level of activity at home. c) the family's psychosocial history. d) the facility's restraint policy.

gait and balance information. Correct Explanation: Assessing the client's gait and balance helps determine his risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and determining the patient's home activity level are important but not as important as gait and balance in relation to the risk of falls

When a client wants to read the medical record, the nurse should: a) give the client the medical record and answer the client's questions. b) tell the client to read the medical record when the health care provider (HCP) makes rounds. c) call the health care provider (HCP) to obtain permission. d) answer any questions the client has without giving the client the medical record.

give the client the medical record and answer the client's questions. Explanation: The client should be allowed to see the medical record. As a client advocate, the nurse should answer questions for the client. The nurse helps the client become a primary partner in the health team. The HCP should not need to give permission for the client to see the medical record. As a client advocate, the nurse should not make excuses to put the client off in regard to seeing the medical record

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a) ground beef patties. b) steamed broccoli. c) ice cream. d) fresh orange slices.

ground beef patties. Explanation: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and: a) have a court appoint a guardian for the client. b) have a hospital quality management coordinator sign for the client. c) have the client put an "X" on the signature line. d) have the client's next-of-kin sign the informed consent.

have the client put an "X" on the signature line. Correct Explanation: The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications, and that consent for the surgery is truly voluntary

A client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should: a) insert a Foley catheter. b) start an intravenous infusion. c) initiate a time-out. d) verify that the surgeon possesses the degree of expertise needed.

initiate a time-out. Correct Explanation: The Universal Protocol is used to prevent wrong site, wrong procedure, and wrong person surgery. Actions included in the protocol are as follows: conduct a preprocedure verification process, mark the procedure site, and perform a time out. Exceptions to the Universal Protocol are routine or "minor" procedures, such as venipuncture, peripheral IV line placement, insertion of oral/nasal drainage or feeding tubes, or Foley catheter insertion. Prior to closure, the surgeon or circulating nurse will initiate a time out to verbally confirm a review of informed consent and procedures completed; all specimens are identified, accounted for, and accurately labeled; and all foreign bodies have been removed. The Chief of Surgery and Medical Director are the ones who will verify the surgeons' levels of expertise.

A nurse is analyzing a client's intake and output. The client has a temperature of 102° F (38.9° C) and is receiving 2400 mL of IV fluids per 24 hours because the client is to have nothing-by-mouth. Before planning nursing actions, the nurse should first determine: a) the intravenous fluid intake during the last 8 hours. b) the client's body mass index. c) when the client last ate. d) insensible fluid loss through the lungs and skin.

insensible fluid loss through the lungs and skin. Explanation: Insensible fluid loss is invisible vaporization from the lungs and skin, and assists in regulating body temperature. The amount of water loss is increased by accelerated body metabolism, which occurs with increased body temperature. The client's body mass index does not directly influence calculating fluid therapy.

A nurse can auscultate for heart sounds more easily if the client is: a) leaning forward. b) holding his breath. c) on his right side. d) supine.

leaning forward. Explanation: The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This position enables the nurse to listen for heart sounds without the sound of expiration interfering. Using the supine position to visually inspect the precordium allows the nurse to observe the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole. Placing the client in a left lateral decubitus position may make it easier for the nurse to hear low-pitched sounds related to atrioventricular valve problems

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: a) a decrease in the left dorsalis pedis and posterior tibial pulses. b) loss of hair on the lower portion of the left leg and foot. c) pallor and coolness of the left foot with decreased sensation. d) left calf circumference 1" (2.5 cm) larger than the right.

left calf circumference 1" (2.5 cm) larger than the right. Correct Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased sensation, decreased pulses, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

The nurse is preparing a 45-year-old female for a vaginal examination. The nurse should place the client in which postion? a) dorsal recumbent position b) lithotomy position c) genupectoral position d) Sims position

lithotomy position Correct Explanation: Although other positions may be used, the preferred position for a vaginal examination is the lithotomy position. This position offers the best visualization. If the client is elderly and frail, staff members may need to support the client's flexed legs while the examiner conducts the examination and obtains the Papanicolaou smear. Positioning the client in the other positions will make visualization more difficult and may not be as comfortable for the client

A nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: a) knee. b) lower thigh. c) ankle. d) lower foot.

lower foot. Explanation: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee will not promote venous return

Which nursing intervention is most important in preventing septic shock? a) obtaining vital signs every 4 hours for all clients b) administering IV fluid replacement therapy as ordered c) monitoring red blood cell counts for elevation d) maintaining asepsis of indwelling urinary catheters

maintaining asepsis of indwelling urinary catheters Correct Explanation: Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention

Which nursing intervention is most important in preventing septic shock? a) maintaining asepsis of indwelling urinary catheters b) obtaining vital signs every 4 hours for all clients c) monitoring red blood cell counts for elevation d) administering IV fluid replacement therapy as ordered

maintaining asepsis of indwelling urinary catheters Correct Explanation: Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? a) preservation of muscle mass b) prevention of bone demineralization c) increase in muscle tone d) maintenance of joint mobility

maintenance of joint mobility Correct Explanation: 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

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. Although the client is ambulatory, the unlicensed assistive personnel (UAP) are concerned about urinary incontinence because the client is frail and in a strange environment. The nurse should instruct the UAP to assist with implementing the nursing plan of care by: a) requesting an indwelling urinary catheter to avoid incontinence b) prescribing adult diapers for the client so she will not have to worry about incontinence c) padding the bed with extra absorbent linens d) placing a commode at the bedside and instructing the client in its use

placing a commode at the bedside and instructing the client in its use Explanation: A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside commode

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which position is appropriate? a) placing a pillow in the axilla so the arm is away from the body b) immobilizing the extremity in a sling c) inserting a pillow under the slightly flexed arm so the hand is higher than the elbow d) positioning a hand cone in the hand so the fingers are barely flexed e) keeping the arm at the side using a pillow

placing a pillow in the axilla so the arm is away from the body • inserting a pillow under the slightly flexed arm so the hand is higher than the elbow • positioning a hand cone in the hand so the fingers are barely flexed Explanation: Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures.

A client undergoing chemotherapy after a modified radical mastectomy asks the nurse questions about a breast prosthesis and wigs. After answering the questions directly, the nurse should also: a) call the home health care agency. b) provide a list of resources, including the local breast cancer support group. c) offer a referral to the social worker. d) contact the plastic surgeon.

provide a list of resources, including the local breast cancer support group. Correct Explanation: Giving the client a list of community resources that could provide support and guidance assists the client to maintain her self-image and independence. The support group will include other women who have undergone similar therapies and can offer suggestions for breast products and wigs. Because the client is asking about specific resources, she does not need a referral to a social worker, home health agency, or plastic surgeon

Arrangements are made for a member of the colostomy support group to meet with a client before bowel surgery. What is accomplished by having a representative from the group meet the client preoperatively? a) convincing the client that he will not be disfigured and can lead a full life b) providing the client with support and realistic information on the colostomy c) letting the client know that he has resources in the community to help him d) providing support for the health care provider's (HCP's) plan of therapy for the client

providing the client with support and realistic information on the colostomy Explanation: Preoperative visits and talks with others who have made successful adjustments to colostomies are helpful and tend to make the client less fearful of the operation and its consequences. Knowing about resources in the community will be helpful as the client approaches discharge. Supporting the HCP is less important than supporting the client and giving him information. The client will have a change in body image, with disfigurement due to the creation of a colostomy. However, the client should be able to lead a full life

The charge nurse on the pediatric floor has assigned a 6-year-old girl with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-private room. The 6-year-old's mother is upset because the parent staying with the other child is male and believes the arrangement is violates her social norms. The nurse should: a) explain to the parents that this room arrangement facilitates teaching. b) offer the 6-year-old's mother another place to sleep. c) reassign the children to different rooms. d) refer the 6-year-old's mother to the customer service representative.

reassign the children to different rooms. Correct Explanation: Sleeping in the same room with a person of the opposite sex may be viewed as a violation of norms by persons of conservative faiths. If at all possible, the charge nurse should reassign the family to a different room. While it makes sense to have two clients with similar educational needs in the same room, it is likely that the arrangement would be distressing enough to create a learning barrier. Offering the mother another place to sleep deprives the child of her parent at night. The customer service representative would only need to be involved if it became impossible to accommodate the mother's needs

A prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to: a) ask the nurse to read the policy book before administering the blood. b) reassign the client to another nurse who is experienced in blood administration. c) give a thorough explanation of the procedure for blood administration to the nurse. d) ask the nurse to determine how confident he or she is to administer the blood safely.

reassign the client to another nurse who is experienced in blood administration. Correct Explanation: The best option in this situation is to reassign the client to a nurse with experience in blood administration. The policy book and explanation are resources, but the nurse is a pediatric nurse who has never administered blood before, and therefore, an unsafe situation is created. An explanation is insufficient teaching for safe and proper blood administration, and reading policy book may be a resource, but having an experienced nurse administer the blood is a safer decision. Asking about the nurse's confidence is not sufficient evidence that the nurse can administer the blood. Asking an experienced nurse to administer the blood is a safer option.

While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should: a) report this to the head nurse when she arrives in the morning. b) report this to the nursing supervisor immediately. c) assess the nurse's behavior for signs of intoxication. d) ask the nurse if she has been drinking.

report this to the nursing supervisor immediately. Explanation: This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation. This situation requires immediate attention and cannot be delayed until the head nurse is available on the day shift. The charge nurse, or another staff nurse, should not confront the nurse; this is the responsibility of the nursing supervisor. Assessment of the nurse's behavior is not the nurse's responsibility; reporting the potentially unsafe situation is.

The nurse notices that a nurse colleague is wearing a lower lip ring. The nurse should: a) page the nurse supervisor to speak with the nurse. b) direct the nurse to go to the Office of Infection Control. c) request that the nurse remove the ring. d) report the nurse to the unit manager.

request that the nurse remove the ring. Correct Explanation: Professionalism in nursing is demonstrated by a nurse's appearance and ownership of actions; appearance is one means of contributing to a positive experience in a health care setting. The nurse should discuss the situation with the colleague first. To go to the manager's office or to direct the colleague to go to the Office of Infection Control will not promptly correct the professional dress code violation. Paging the nursing supervisor does not follow the line of command for reporting problems. Nurses must support professionalism; dress is an aspect of professionalism

A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based on the theory that it: a) blocks nerve pathways to the brain. b) restores the balance of energy. c) purges evil spirits. d) promotes tranquility.

restores the balance of energy. Correct Explanation: Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to: a) arrange a meeting of the day-shift and night-shift nurses. b) review the capillary glucose monitoring calibration log book. c) immediately remind the night-shift nurses of the daily calibrations. d) counsel the night charge nurse about the discrepancy.

review the capillary glucose monitoring calibration log book. Explanation: When dealing with complaints, a nurse-manager should always gather data before taking action. Therefore, the nurse-manager should review the calibration documentation, then address the findings. It would be inappropriate for the nurse-manager to remind the staff of a responsibility that they may be fulfilling, arrange a meeting that could become confrontational, or counsel the charge nurse before investigating and gathering data relative to the complaint

In her first postpartum month, a client has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after the birth of her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication the nurse is using is: a) reflection. b) clarification. c) self-disclosure. d) restating.

self-disclosure. Correct Explanation: Self-disclosure involves the nurse revealing personal information. Using self-disclosure as a therapeutic communication technique facilitates an open and authentic relationship between the nurse and her client. Clarification involves the nurse asking the client for more information. Reflection involves reviewing the client's ideas. Restating is the nurse's repetition of the client's main message

An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms? a) serum osmolality b) platelet count c) urine specific gravity d) serum sodium

serum sodium Explanation: This client is exhibiting behaviors and symptoms associated with hyponatremia caused by water intoxication; the nurse would expect to find confirmation of a low serum sodium level by checking the electrolyte levels. The nurse would expect this client's serum osmolality and urine specific gravity to be low, not high.

The client with an abdominal hysterectomy is being prepared for discharge in the morning. The client has a handicapped adult son whom she cares for at home. The nurse should discuss with the health care provider (HCP) the need for referral to: a) volunteer services. b) social work. c) home health care. d) pastoral care.

social work. Explanation: The social worker will be able to coordinate respite care for the son and other community resources for this family. Home health care would provide care for the client herself, but respite care for the son is the priority need for this family. Pastoral care provides spiritual care. The volunteer department would not be responsible for coordination of care at the client's home.

A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources? a) dietitian b) social worker c) infection control nurse d) pharmacist

social worker Correct Explanation: The social worker is the most essential team member to be involved in discharge planning to meet the client's needs and offer suggestions for the best community resources.

A client who has had the jaws wired begins to vomit. The nurse should first: a) administer an antiemetic intravenously. b) insert a nasogastric (NG) tube and connect it to suction. c) use wire cutters to cut the wire. d) suction the client's airway as needed.

suction the client's airway as needed. Correct Explanation: The nurse's first action is to clear the client's airway as necessary. Inserting an NG tube or administering an antiemetic may prevent future vomiting episodes, but these procedures are not helpful when the client is actually vomiting. Cutting the wires is done only as a last resort or in case of respiratory or cardiac arrest

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first: a) prepare for transcutaneous pacing. b) auscultate for abnormal heart sounds. c) take the client's blood pressure. d) administer atropine 0.5 mg IV push.

take the client's blood pressure. Correct Explanation: The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

Which indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client: a) takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. b) breathes in through the mouth and out through the nose. c) breathes in through the nose and out through the mouth. d) uses diaphragmatic breathing in the lying, sitting, and standing positions.

takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. Correct Explanation: The correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply. a) that the client understood the information b) that there was voluntary consent on the client's part c) that there was adequate disclosure of information d) that the client's relative, spouse or legal guardian was present e) that the client has full awareness of the potential complications

that there was adequate disclosure of information • that the client has full awareness of the potential complications • that there was voluntary consent on the client's part • that the client understood the information Correct Explanation: The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will. It is not necessary for a spouse, relative, or guardian to be present

A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent? a) the surgeon b) the anesthesiologist c) the nurse d) the social worker

the surgeon Correct Explanation: It is the role of the surgeon or the person performing the procedure to obtain the informed consent. This consists of informing the client about the procedure, the risks of treatment, the side effects, other types of treatments available, and the effects without the procedure. Nurses, anesthesiologists, and social workers do not obtain informed consent.

When examining a client who has abdominal pain, a nurse should assess: a) the symptomatic quadrant either second or third. b) the symptomatic quadrant last. c) the symptomatic quadrant first. d) any quadrant first.

the symptomatic quadrant last. Correct Explanation: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment

A nurse is planning staffing for a nursing unit in which the primary need of the clients is learning how to manage their health problems. Which combination is the ideal mix of staff for this unit? a) three registered nurses (RNs) b) one RN and two licensed practical/vocational nurses (LPNs/VNs) c) one LPN/VN and two unlicensed assistive personnel (UAPs) d) one RN, one LPN/VN, and one UAP

three registered nurses (RNs) Explanation: The ideal staffing for a nursing unit focused on client teaching and learning is to have three registered nurses. It is within the scope of practice for the RN to assess, plan, implement, coordinate, and evaluate client learning. It is not within the scope of practice for LPNs/VNs and UAP to provide client teaching

Which sign is an early indication that a client has developed hypocalcemia? a) depressed reflexes b) ventricular dysrhythmias c) memory changes d) tingling in the fingers

tingling in the fingers Correct Explanation: Neuromuscular irritability is usually the first indication that a client has developed a low serum calcium level. Numbness and tingling around the mouth as well as in the extremities is an early sign of neuromuscular irritability. Depressed reflexes, decreased memory, and ventricular dysrhythmias are indications of hypercalcemia

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client? a) fluid intake less than urinary output b) blood pressure of 90/60 mm Hg c) an increase in body weight d) urine output greater than 35 mL/hou

urine output greater than 35 mL/hour Correct Explanation: A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client? a) urine output greater than 35 mL/hour b) blood pressure of 90/60 mm Hg c) fluid intake less than urinary output d) an increase in body weight

urine output greater than 35 mL/hour Correct Explanation: A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: a) massage the abdomen once a shift. b) elevate the lower extremities. c) use an alternating air pressure mattress. d) institute range-of-motion (ROM) exercise every 4 hours.

use an alternating air pressure mattress. Correct Explanation: Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling.

A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to: a) walk with help in the hallway by the end of the evening shift. b) change his own dressing with clean technique and be able to verbalize the steps. c) select special foods from a diet after client education by the nurse. d) walk from his room to the end of the hall and back before discharge.

walk from his room to the end of the hall and back before discharge. Correct Explanation: Walking from the client's room to the end of the hall and back before discharge is a specific, measurable, attainable, and timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse makes which observation? a) placement of bloody sheets in a container designated for contaminated linens b) use of protective goggles during a cesarean birth c) disposal of used scalpel blades in a puncture-resistant container d) wearing of sterile gloves to bathe a neonate at 2 hours of age

wearing of sterile gloves to bathe a neonate at 2 hours of age Correct Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate.

Which is the most accurate method of determining the extent of a client's fluid loss? a) weighing the client b) measuring intake and output c) assessing vital signs d) assessing skin turgor

weighing the client Explanation: Accurate daily weight measurement provides the best measure of a client's fluid status: 1 kg (2.2 lb) is equal to 1,000 mL of fluid. To be accurate, weight should be obtained at the same time every day, with the same scale, and with minimal clothing on

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes." The nurse explains that this variation is based on the fact that nurses: a) work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. b) are at greater risk from the radiation because they are younger than the mother. c) touch the client, which increases their exposure to radiation. d) work with many clients and could carry infection to a client receiving radiation therapy, if exposure is prolonged.

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Explanation: The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years

A child has a nasogastric (NG) tube inserted by the nurse to administer a continuous feeding. Which of the following actions should the nurse take before starting the NG feeding on the child? Select all that apply. a) Prepare a 24-hour supply of formula. b) Check placement of the NG tube. c) Assess for bowel sounds. d) Verify the physician's order. e) Heat the formula in a microwave.

• Check placement of the NG tube. • Assess for bowel sounds. • Verify the physician's order. Correct Explanation: Verifying the order, checking the placement of the NG tube, and assessing bowel sounds are necessary before initiating an NG feeding. Formula should not be heated in the microwave, and no more than a 4-hour supply should be hung to prevent the growth of microorganisms

A 20-year-old seeks treatment at a local emergency care center after spraining his ankle while playing football with friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician? Select all that apply. a) Tell the client that pain typically worsens 24 hours after the injury. b) Provide crutch-gait training. c) Instruct the client to elevate the ankle for 48 to 72 hours. d) If needed, apply an elastic bandage from the toes to midcalf. e) Initially apply cold pack.

• Initially apply cold pack. • Instruct the client to elevate the ankle for 48 to 72 hours. • Provide crutch-gait training. • If needed, apply an elastic bandage from the toes to midcalf. Explanation: Pain caused by an injury is best treated initially with cold applications. Cold reduces localized swelling and decreases vasodilation. Decreasing vasodilation prevents pain-producing chemicals from entering the circulation. The client should be instructed to call the physician if pain worsens or persists. Additional radiographs may be necessary to detect a fracture that might have originally been missed. The client should also be instructed to elevate the joint for 48 to 72 hours after the injury. If an elastic bandage is needed, the nurse should wrap the bandage from toes to midcalf, forming a figure eight, and teach the client how to reapply it. The nurse should ensure that the client also receives crutch-gait training

The client has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply. a) Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). b) Notify the health care providers (HCPs) at the surgery center. c) Ask to have the surgery at a hospital. d) Wear a stainless steel medical alert bracelet into the surgical suite. e) Determine that there will be a latex-safe environment for surgery.

• Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). • Notify the health care providers (HCPs) at the surgery center. • Determine that there will be a latex-safe environment for surgery. Correct Explanation: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs and symptoms of latex allergy may range from mild to anaphylaxis. Clients with latex allergy are advised to notify their HCPs and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current. The surgery can be safely performed at a free-standing surgery center as long as latex precautions are observed.

A young woman will receive 6 months of chemotherapy for cervical cancer. She is a single parent of two young children and can no longer work. The nurse contacts a social worker to help plan continuing care. The client states, "I feel overwhelmed. How can the social worker help me?" Which responses by the nurse about the role of the social worker are appropriate? Select all that apply. a) "The social worker can authorize temporary funds to help you with child care and to pay your bills while you are sick." b) "The social worker is a part of a multidisciplinary team that helps plan care for clients with cancer." c) "The social worker can assist in locating resources and programs to assist you during your treatment." d) "Based on your financial situation and need to care for your children, the social worker can help you identify needed resources at this time." e) "Your entire family will be included in the treatment plan. Your needs and those of your children will be assessed and determined so that referrals can be made to appropriate resources."

"The social worker is a part of a multidisciplinary team that helps plan care for clients with cancer." • "The social worker can assist in locating resources and programs to assist you during your treatment." • "Based on your financial situation and need to care for your children, the social worker can help you identify needed resources at this time." • "Your entire family will be included in the treatment plan. Your needs and those of your children will be assessed and determined so that referrals can be made to appropriate resources." Explanation: The social worker is part of the comprehensive, holistic health care team. Because the client is now unemployed and is a single parent, the social worker can provide information about sources of financial support. The needs of the client and the family members are included in the treatment plan. The social worker cannot authorize temporary funds

As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond? a) "Hospital policy requires us to have your wife sign this. That doesn't mean that we expect anything to go wrong." b) "We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them." c) "Everyone who is admitted to this facility must sign this. We need to know what we should do in case something unexpected happens." d) "I hate talking about this because it may upset you. Federal law requires your wife to sign this and there is nothing we can do about that."

"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them." Correct Explanation: Telling the client's husband that clients have the right to specify advance directives and appoint someone to speak for them provides factual information. The other options don't answer the husband's question or provide the information he requested

The nurse is coaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking: a) "What do you know about your medications and condition?" b) "What is required for your family to manage your symptoms?" c) "How much does your family need to be involved in learning about your condition?" d) "What activities are most important for you to be able to maintain control of your diabetes?"

"What activities are most important for you to be able to maintain control of your diabetes?" Correct Explanation: Empowerment is an approach to clinical practice that emphasizes helping people discover and use their innate abilities to gain mastery over their own condition. Empowerment means that individuals with a health problem have the tools, such as knowledge, control, resources, and experience, to implement and evaluate their self-management practices. Involvement of others, such as asking the client about family involvement, implies that the others will provide the direct care needed rather than the client. Asking the client what the client needs to know implies that the nurse will be the one to provide the information. Telling the client what is required does not provide the client with options or lead to empowerment

A 24-year old client who has diabetes mellitus accidentally cut herself while preparing dinner and has sustained a large laceration on her left wrist. After the laceration is sutured, the client asks the nurse, "How long will it take for my scars to disappear?" Which statement is the nurse's best response? a) "The contraction phase of wound healing can take 2 to 3 years." b) "With your history and the type and location of your injury, it's hard to say." c) "Wound healing is very individual but the scar should fade within 4 months." d) "If you don't develop an infection, the wound should heal in 1 to 3 years."

"With your history and the type and location of your injury, it's hard to say." Explanation: In a client with diabetes, wound healing will be delayed. Providing a specific time frame could give the client false information.

A client with severe chest pain is brought to the emergency department. The client tells the nurse, "I just have a little indigestion." How should the nurse respond? a) "How will having chest pain change your life?" b) "Are you confused? You are having a heart attack." c) "We tried an antacid and it did not work. It is not indigestion." d) "You seem concerned about your chest pain."

"You seem concerned about your chest pain." Correct Explanation: During a crisis, it's common for a client to use denial, a coping mechanism exhibited by minimizing symptoms or avoiding discussion. The nurse must respond therapeutically to the client. Confrontation about the client's statement and asking the client if he/she is confused are not therapeutic. Asking how having chest pain will change the client's life is not appropriate in this acute phase

A client, age 40, is admitted for treatment of a breast tumor. She asks the nurse, "Do you think I have cancer?" Which response by the nurse is most therapeutic? a) "You sound concerned about what the physicians will tell you." b) "We won't know for sure until you undergo some tests." c) "Your physician can tell you more about that." d) "Most women your age have some kind of breast problem."

"You sound concerned about what the physicians will tell you." Correct Explanation: This response allows the client to express her feelings and promotes further discussion. Referring the client to the physician ends the discussion and prevents exploration of the client's feelings. Generalizing about most women shifts the focus from the client. The statement about the need for tests is true but doesn't focus on the client's feelings and concerns.

Which client is at increased risk for developing a wound infection? a) A client with a body mass index (BMI) of 27. b) A client with a hemoglobin of 11.4. c) A client that does not ambulate on first post-op day. d) A client with an albumin level of 2.4 g/dl.

A client with an albumin level of 2.4 g/dl. Correct Explanation: Nutrition plays an important role in wound healing. Because vitamins and protein are essential for wound healing, a client with an albumin level less than 3.0 g/dl is considered malnourished and is at increased risk for developing a wound infection. Frequent pain medication allows the client to be more comfortable and does not increase risk of infection. A client not ambulating on post-op day 1 is at greater risk of deep vein thrombosis and pneumonia. A client who has a BMI of 27 is considered overweight and isn't at increased risk for developing a wound infection

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a) Medication record. b) A graphic sheet. c) 24-hour fluid balance record. d) Acuity charting forms.

A graphic sheet. Correct Explanation: A graphic sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to their conditions and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs

Which situation violates the a client's privacy? a) A nurse gives a client's family members details of his condition from his medical records b) A nurse allows a nursing student to review a client's chart the day before the student will be working on the unit. c) A nurse gives a client his chart and stays with him while he reads the new orders. d) When planning a client's discharge care, medical students discuss his home situation.

A nurse gives a client's family members details of his condition from his medical records Correct Explanation: A nurse may not give information about a client to anyone without that client's consent. Nursing students and medical students may review client charts for the purpose of instruction and learning. The client has the right to see his chart. By remaining with the client while he reviews his chart, the nurse can explain notations that are confusing or unclear.

Which situation violates the a client's privacy? a) A nurse gives a client's family members details of his condition from his medical records b) When planning a client's discharge care, medical students discuss his home situation. c) A nurse allows a nursing student to review a client's chart the day before the student will be working on the unit. d) A nurse gives a client his chart and stays with him while he reads the new orders.

A nurse gives a client's family members details of his condition from his medical records Explanation: A nurse may not give information about a client to anyone without that client's consent. Nursing students and medical students may review client charts for the purpose of instruction and learning. The client has the right to see his chart. By remaining with the client while he reviews his chart, the nurse can explain notations that are confusing or unclear.

A client asks the nurse why the prostate specific antigen (PSA) level is determined before the digital rectal examination. The nurse's best response is: a) "A prostate examination can possibly increase the PSA." b) "If the PSA is normal, the client will not have to undergo the rectal examination." c) "It is easier for the client." d) "A prostate examination can possibly decrease the PSA."

A prostate examination can possibly increase the PSA." Correct Explanation: Manipulation of the prostate during the digital rectal examination may falsely increase the PSA levels. The PSA determination and the digital rectal examination are no longer recommended as screening tools for prostate cancer. Prostate cancer is the most common cancer in men and the second leading killer from cancer among men in the United States and Canada. Incidence increases sharply with age, and the disease is predominant in the 60- to 70-year-old age group

After many years of advanced practice nursing, a nurse has recently enrolled in a nurse practitioner (NP) program. This nurse has been attracted to the program by the potential after graduation to provide primary care for clients, an opportunity that is most likely to exist in which of the following settings? a) A rural health center. b) A university hospital. c) A community hospital. d) A long-term care facility.

A rural health center. Explanation: Many rural health centers employ few healthcare providers, and primary care is often provided by an NP. An NP may provide care in a long-term care facility or hospital, but in these settings, the NP is less likely to be the provider of primary care to clients.

A nurse is working within the managed care delivery model. Which of the following is true regarding managed care? a) All systems reflect the values of efficiency and effectiveness. b) All plans have the same values underlying the delivery of care. c) There are no conflicts between cost-effectiveness and respectful care. d) Their values are not reflected in the decision making.

All systems reflect the values of efficiency and effectiveness. Correct Explanation: All systems in the managed care delivery model reflect the values of efficiency and effectiveness. Different plans may have different values underlying the delivery of care. However, they all reflect the business plan values of efficiency and effectiveness. Their values are reflected in the decision making and the policy development of the organization. Value conflicts between cost-effectiveness and respectful care may be seen.

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? a) Advocating for the client by ordering Meals on Wheels 5 days a week b) Notifying the American Cancer Society (Canadian Cancer Society) of the client's diagnosis c) Asking the physician to write an order for home skilled nursing assessments and interventions d) Asking an occupational therapist to evaluate the client at home

Asking the physician to write an order for home skilled nursing assessments and interventions Correct Explanation: Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for home health care. The American Cancer Society (Canadian Cancer Society) often sponsors support groups, which are helpful when the person is ready. However, contacting this organization would break client confidentiality, and even with the client's consent does not take precedence over ensuring proper home health care. Advocating for Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation.

A client reports abdominal pain. Which action allows the nurse to investigate this complaint? a) Assessing the painful area first b) Using deep palpation c) Checking for warmth in the painful area d) Assessing the painful area last

Assessing the painful area last Correct Explanation: Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when she will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain

A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care? a) Assisting the client with bathing and dressing by giving clear, simple directions b) Drawing up a schedule and making certain that it is adhered to c) Devising a bathing and dressing schedule for each morning d) Bathing and dressing the client each morning until the client is willing to perform self-care independently

Assisting the client with bathing and dressing by giving clear, simple directions Correct Explanation: This action would provide a disorganized client with the necessary structure to encourage participation and support of self-image. The other answers are incorrect because they do not support nurse promotion of client health. The client is not confused and does not require a schedule; however, the client does need some assistance. Full assistance is not required.

A Malaysian client is admitted to the health care facility with reports of cramping pain in the abdomen and loose stools. Where should the nurse be seated when interviewing the client? a) Alongside the client. b) In the corner of the room. c) At more than one arm's distance. d) Behind the client.

At more than one arm's distance. Correct Explanation: While interviewing the Malaysian client, the nurse should sit at a distance of more than one arm's length from the client. The nurse should not sit alongside the client, because the client may feel uncomfortable. If the nurse sits at the back of the client, the nurse may not be able to observe the client's body language. If the nurse sits in a corner of the room, communication may not be effective.

A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask: a) "Where does it hurt the most?" b) "Do you have the pain all the time?" c) "Can you describe the pain?" d) "Is the pain stabbing like a knife?"

"Can you describe the pain?" Correct Explanation: Asking an open-ended question such as "Can you describe the pain?" encourages the client to describe any and all aspects of the pain in his own words. The other options are likely to elicit less information because they're more specific and would limit the client's response

A hospital uses the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? a) "2 mg hydromorphone PO administered with good effect." b) "Client has a history of recent abdominal pain." c) "Client is guarding her abdomen and occasionally moaning." d) "Client reporting abdominal pain rated at 8/10."

"Client reporting abdominal pain rated at 8/10." Explanation: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a report of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be best? a) "Your physician can discuss this in more detail." b) "You sound concerned about what's happening." c) "Most people your age develop some type of colon problem." d) "You'll have to have some tests before the physician can rule out cancer."

"You sound concerned about what's happening." Explanation: This response conveys empathy and invites further discussion of the client's concerns. The other options block communication by failing to address the client's concerns and feelings.

As the nurse helps a client to the bathroom, the client says, "When you get to the point where you can't even go to the bathroom by yourself, you might as well be dead." Which response by the nurse is most therapeutic? a) "You're making great progress. A week ago, you couldn't even get out of bed." b) "You sound really discouraged today." c) "Why are you feeling so down today? This isn't like you." d) "Keep your chin up. Things will look better tomorrow."

"You sound really discouraged today." Correct Explanation: Sharing an observation with the client conveys awareness of his feelings and promotes further communication. Spouting clichés, disagreeing with the client, or asking why the client feels a certain way doesn't promote therapeutic communication

The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he will not get the right care if he gets sick at college." The nurse should tell the parent: a) "Your son can make an e-health history to facilitate his care if he gets sick away from home." b) "I can have his records sent to the school's health center." c) "Make sure your son always carries his nephrologist's phone number." d) "Your son is going to need to learn to manage his own disease."

"Your son can make an e-health history to facilitate his care if he gets sick away from home." Correct Explanation: Access to a well-constructed e-history will facilitate care if the adolescent becomes ill while at college. Because the client is 18, legally the nurse cannot transfer the records to the school without permission. Also, the adolescent may need to seek treatment in facilities other than the health center. Instructing the adolescent to always carry the nephrologist's phone number is not bad advice, but compliance may vary and there is no guarantee the provider will be available in all instances. Telling the parent that the son must learn to manage his own disease does not address the parent's concern.

A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation? a) "Could you clarify for me whether you were joking with the client?" b) "Your verbal threats to the client are legally considered assault." c) "I will have to report you for unprofessional behavior toward a client." d) "I think you need to review therapeutic communication techniques."

"Your verbal threats to the client are legally considered assault." Correct Explanation: Assault is conduct that makes a person fearful and produces a reasonable apprehension of harm. The nurse's behavior in legal terms is assault.

A client is being admitted with a nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with a: a) 45-year-old client with abdominal hysterectomy. b) 24-year-old client with non-Hodgkin's lymphoma. c) 60-year-old client admmitted for investigation of transient ischemic atttacks. d) 55-year-old client with alcoholic cirrhosis.

60-year-old client admmitted for investigation of transient ischemic atttacks. Correct Explanation: The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised. The client with a recent surgery and incision should not be exposed to a client with infection. Clients with cancer or alcoholic cirrhosis are very susceptible to infection, and it would not be safe to expose them to a client with a respiratory infection

A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff? a) A staff nurse fills a client prescription at the hospital pharmacy because the pharmacist on duty is busy. b) A nursing assistant attempts to initiate I.V. therapy. c) A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. d) A nursing assistant administers medications to a client in ICU.

A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. Correct Explanation: The nurse-manager is legally responsible for actions that fall within the scope of practice of the staff members who perform them. A nurse may not knowingly administer or perform tasks that will harm a client. It's within a nurse's scope of practice to refuse to carry out such orders. A nurse-manager can't be held legally responsible for the nurse's refusal in this situation. Administering medications and initiating I.V. therapy aren't within the scope of practice for nursing assistants, and a staff nurse isn't licensed to fill prescriptions.The nurse-manager can be held legally responsible for these actions

Which component of an outcome criterion must the nurse consider when setting goals for a client? a) A family member b) A focal point c) A place d) A time frame

A time frame Correct Explanation: The nurse must consider four major components in writing outcome criteria: the content area, an action verb, a time frame, and criterion modifiers. Including a time frame (a target date for completion of the expected outcome criterion) helps the nurse evaluate the client's progress. A place, a family member, and a focal point aren't components of an outcome criterion

A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. A subculture is best described as which of the following? a) A cultural group with fewer than 5 million members in the United States. b) A unique cultural group that exists within the larger culture. c) A cultural group with values that are incongruent with those of the dominant culture. d) A unique cultural group with unspecified geographic origins.

A unique cultural group that exists within the larger culture. Correct Explanation: Subcultures are unique cultural groups that coexist within the dominant culture of the United States. Subcultures are not defined according to the size of their membership or the lack of specific geographic origins. Subcultures may have some values that differ from those of the dominant culture, but this is not their defining characteristic.

Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C); a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority? a) Anxiety b) Risk for imbalanced body temperature c) Decreased cardiac output d) Acute pain

Acute pain Explanation: The nursing diagnosis of Acute pain takes highest priority because it increases the client's pulse and blood pressure. During the acute phase of an MI, low-grade fever is an expected result of the body's response to myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis, but addressing Acute pain (the priority concern) may alleviate the client's anxiety

A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation? a) Ask the nurse if this is acceptable practice for this unit. b) Advise the nurse that he/she can be accused of battery. c) Inform the nurse that he/she can be accused of negligence. d) Notify the licensing body of the nurse's behavior.

Advise the nurse that he/she can be accused of battery. Explanation: Battery is defined as an intentional and wrongful physical contact with a person that entails an injury or offensive touching. The other options are not correct because they do not describe the nurse's behavior

While meeting with the nurse, a client's wife states, "I do not know what else to do to make him stop drinking." The nurse should refer the wife to which organization? a) an employee assistance program b) Alateen c) Alcoholics Anonymous d) Al-Anon

Al-Anon Correct Explanation: Al-Anon is a self-help group for spouses and significant others that provides education and support and helps participants learn to lead their own life without feeling responsible for the individual with an alcohol problem. Alateen provides support for teenaged children of a person with an alcohol problem. Employee assistance programs help employees recover from alcohol or drug dependence while retaining their positions or jobs. Alcoholics Anonymous provides support for the individual with alcohol problems to attain and maintain sobriety.

A nurse is working within the managed care delivery model. Which of the following is true regarding managed care? a) There are no conflicts between cost-effectiveness and respectful care. b) Their values are not reflected in the decision making. c) All plans have the same values underlying the delivery of care. d) All systems reflect the values of efficiency and effectiveness.

All systems reflect the values of efficiency and effectiveness. Correct Explanation: All systems in the managed care delivery model reflect the values of efficiency and effectiveness. Different plans may have different values underlying the delivery of care. However, they all reflect the business plan values of efficiency and effectiveness. Their values are reflected in the decision making and the policy development of the organization. Value conflicts between cost-effectiveness and respectful care may be seen

Which of the following circumstances likely requires the most documentation and communication by the nurse? a) A client is being transferred from one medical unit of the hospital to another to accommodate another client on isolation precautions. b) An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. c) A client is returning to her assisted-living facility following her colonoscopy earlier that day. d) A client is being discharged home following a laparoscopic appendectomy 2 days earlier.

An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. Correct Explanation: Transfer from the hospital setting to a long-term care facility is likely to require significant documentation and communication from the nurses facilitating the transfer. This may include copying the chart or summarizing a large amount of relevant data. Transfers within a hospital typically require somewhat less documentation and communication, while discharges home or to an existing facility may not require a formal report of any type

Which of the following circumstances likely requires the most documentation and communication by the nurse? a) A client is being transferred from one medical unit of the hospital to another to accommodate another client on isolation precautions. b) An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. c) A client is being discharged home following a laparoscopic appendectomy 2 days earlier. d) A client is returning to her assisted-living facility following her colonoscopy earlier that day.

An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. Explanation: Transfer from the hospital setting to a long-term care facility is likely to require significant documentation and communication from the nurses facilitating the transfer. This may include copying the chart or summarizing a large amount of relevant data. Transfers within a hospital typically require somewhat less documentation and communication, while discharges home or to an existing facility may not require a formal report of any type.

A nurse-manager must include which items as part of the personnel budget? a) Office supplies for secretarial use b) Computers for staff use c) Anticipated overtime payments for staff d) Videos for staff education

Anticipated overtime payments for staff Explanation: Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Any expense or single item of equipment costing more than $500 is part of the capital budget. Office supplies and videos are part of the operating budget

A client who fell through ice and was submerged for longer than 1 minute is admitted to the emergency department with hypothermia and near-drowning. At which point will the nurse best be able to determine the client's outcome status? a) After the parents' initial visit b) Three days after the incident c) As soon as cardiopulmonary resuscitation is successfully initiated d) As soon as the client is warmed

As soon as the client is warmed Explanation: The neural or hemodynamic status of the client cannot be determined until the client is warmed. The nurse would not have to wait 3 days to do so or wait for the parents' initial visit. The determining factor is the client's core body temperature

A young man makes an appointment to see the psychiatric nurse at the Employee Assistance Program of a large corporation beacuse his boss is sending him provocative e-mails and making seductive remarks on his voice mail at home. The nurse informs him about corporate workplace violence guidelines, and he agrees to work with corporate security on the issue. What should the nurse do next? a) Report the incident to the client's coworkers who are at risk for similar harassment. b) Refer the client to his boss's supervisor to file a report. c) Suggest the client contact human resources to request a job transfer. d) Ask the client about his reactions to this situation.

Ask the client about his reactions to this situation. Explanation: It is important to know the client's reactions in order to plan appropriate interventions. Until the client's reactions are known, it is premature to suggest a job transfer, file a report to his boss's supervisor, or alert his coworkers

The nurse is preparing a client who has pancreatic cancer for surgery, during which the client will have a Whipple procedure. The client says she is Catholic but never really goes to church or prays much. She is crying and very frightened. What is the most appropriate action the nurse can do for the client before the surgery? a) Consult the physician for prn medication. b) Ask the client if she would like to see a priest. c) Leave the client so she can reflect on her life. d) Give the client something for anxiety.

Ask the client if she would like to see a priest. Correct Explanation: Even when daily prayers or other religious practices are not a routine part of a client's life, they often assume importance during life transitions, such as loss of a loved one, accident, or serious illness. It would not be appropriate to leave the client to reflect on her life. Contacting the physician for prn medication or something for anxiety for the client would not be the most appropriate action the nurse can take at this time

Which of the following is an important consideration when the nurse is providing culturally competent care in a community clinic? a) Explaining that multiculturalism means all cultures melding to assimilate into one culture b) Informing the client about preferred health interventions and making decisions for the client c) Asking about cultural beliefs related to health, illness, treatments, and dietary practices d) Knowing about different cultural practices and generalizing when caring for clients from that culture

Asking about cultural beliefs related to health, illness, treatments, and dietary practices Correct Explanation: It is a nursing obligation to practice in a culturally sensitive and competent manner. This answer elicits key information regarding the client's beliefs, values, and cultural practices. This also indicates willingness to learn and be respectful of different beliefs and practices. Knowledge is important, but individualizing rather than generalizing is critical. The other choices are inaccurate because they involve making decisions for the client and explaining that the aim is for all cultures to become one.

A 12-year-old African-American boy has experienced significant blood loss and may require a blood transfusion. The boy's mother, father, and sisters are currently present at his bedside in the emergency department. How should the nurse direct questions and teaching about his condition and treatment? a) Assess who is the dominant member of the family and then address that person. b) Direct questions to the family collectively to avoid presuming who is dominant. c) Address the mother, as African-American families are commonly matriarchal. d) Ask the boy's father what should be done, but make eye contact with everyone in the room.

Assess who is the dominant member of the family and then address that person. Explanation: While African-American families are often matriarchal, this fact does not mean that the nurse should not assess the structure and roles of the family on an individual basis. This assessment is preferable to acting on a generalization, even if it is a generalization that may be accurate for many families who are culturally similar.

A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? a) Chicken cutlet, spinach, and soda b) Baked beans, hamburger, and milk c) Bouillon, spinach, and soda d) Spaghetti with cream sauce, broccoli, and tea

Baked beans, hamburger, and milk Correct Explanation: Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse determines that the student has correctly palpated the client's maxillary sinuses when the student palpates which area? a) Below the client's eyebrows b) Below the client's cheekbones c) Over the client's temporal area d) On the bridge of the client's nose

Below the client's cheekbones Correct Explanation: To palpate the maxillary sinuses, the nurse should place her hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places her thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area

A client is admitted to the preoperative clinic for a breast biopsy. Which information would the nurse enter into the medical record as objective data? a) Anxiety level of client is rated at 7 out of 10. b) Blood pressure 130/90 mm Hg; pulse 100 bpm; respirations 14 breaths/min c) Client states, "I am worried about the results." d) Left breast is tender to touch.

Blood pressure 130/90 mm Hg; pulse 100 bpm; respirations 14 breaths/min Correct Explanation: Objective data is information that the nurse observes or collects by observation. The other options fall into the subjective data category of information.

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? a) Send the nurse's assistant to the x-ray department to bring the client back to his room. b) Bring a small glass of juice, and locate the client. c) Check the computerized care plan to determine what test was scheduled. d) Call the client's health care provider (HCP).

Bring a small glass of juice, and locate the client. Correct Explanation: Glulisine is a rapid-acting insulin with an action onset of 15 minutes. The client could experience hypoglycemia with the insulin in the bloodstream and no breakfast. It is not necessary to call the client's HCP; the nurse should determine what test was scheduled and then locate the client and provide either breakfast or 4 oz (120 mL) of fruit juice. To bring the client back to the room would be wasting valuable time needed to prevent or correct hypoglycemia.

A nurse is taking care of two clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50 mm Hg. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next? a) Ask another nurse to verify the compatibility of both units at the same time. b) Call for and hang the first client's blood transfusion. c) Call for both clients' blood transfusions at the same time. d) Ask another nurse to call for and hang the blood for the second client.

Call for and hang the first client's blood transfusion. Explanation: When two clients are to receive blood at the same time, the nurse should call for and hang the clients' transfusions separately to avoid error. The nurse should call for and hang the first client's blood first because this client has experienced a change in blood pressure over a short period of time. The nurse should next call and hang the second client's blood transfusion as there is no indication that this client is unstable at this time. The nurse should not call for both units of transfusions at the same time due to the increased risk of misidentification. The nurse should not verify compatibility of both units at the same time due to the increased risk of misidentification. It is not necessary to involve two nurses because the second client can wait until the nurse has time to hang the blood

A nurse working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which of the following documentation methods should the nurse suggest? a) Medication administration records. b) Charting by exception. c) Focus data, action, and response note. d) Problem, intervention, and evaluation note.

Charting by exception. Correct Explanation: The nurse should suggest the use of charting by exception, which is an abbreviated form of documentation. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a focus can be a problem area, but does not need to be. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The medication administration record documents only medication administration

When cleaning the skin around an incision and drain site, what should the nurse do? a) Clean from the incision to the drain site. b) Clean the incision and drain site simultaneously. c) Clean the incision and drain site separately. d) Clean from the drain site to the incision.

Clean the incision and drain site separately. Correct Explanation: When cleaning the skin around an incision and drain, the nurse should clean the incision and drain separately to avoid contaminating either wound. This is applying the principle of working from the least contaminated area to the most contaminated area. In this case, both areas are fresh wounds and should be kept separate

The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data? Select all that apply. a) Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. b) Client appeared angry and belligerent all shift. c) Client's dressing is intact with scant amount of serous drainage. d) Client ambulated to end of hallway. e) Client seems to be very depressed.

Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. • Client's dressing is intact with scant amount of serous drainage. • Client ambulated to end of hallway. Correct Explanation: Client vital signs, observation of a dressing, and documentation of the activity of a patient represent objective data. Using words such as "seems" or "appears" implies subjectivity on the part of the nurse

Nurses' observance of professional rituals helps standardize practice and ensure efficiency. Which of the following is a characteristic of rituals? a) Preconceived and untested beliefs about people. b) Viewing one's own culture as the only correct standard. c) Common and observable expressions of culture. d) Belief system held to varying degrees as absolute truth.

Common and observable expressions of culture. Correct Explanation: Rituals are common and observable expressions of culture. A preconceived and untested belief about people is called a stereotype. Viewing one's own culture as the only correct standard is ethnocentrism. A belief system held to varying degrees as absolute truth is referred to as culture.

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse? a) Discuss the matter with the night nurse the next time she works. b) Complete an incident report. c) Evaluate the client's BP for 4 hours before making decision. d) Ask the charge nurse if an incident report is necessary.

Complete an incident report. Correct Explanation: Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority.

A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response? a) Confer with the HCP about whether a less expensive drug could be prescribed. b) Instruct the mother on the importance of the medication. c) Ask the mother if she has considered using any medical assistance programs in her community. d) Consult with the social worker.

Confer with the HCP about whether a less expensive drug could be prescribed. Explanation: The nurse must act as an advocate for the client when the client cannot afford treatment. It may be possible to substitute a less expensive antibiotic. Correct procedure includes contacting the HCP to explain the mother's economic situation and request a substitution. For example, amoxicillin is more economical than azithromycin. If it is not possible to use another antibiotic, then the nurse can explore other avenues with the mother and/or social worker.

A health care provider (HCP) prescribes a lengthy x-ray examination for a client with osteoarthritis. Which action by the nurse would demonstrate client advocacy? a) Contact the HCP to determine if an alternative examination could be scheduled. b) Request a prescription for acetaminophen prior to the examination. c) Request padding for the hard x-ray table. d) Contact the X-ray department, and ask the technician if the lengthy session can be divided into shorter sessions.

Contact the X-ray department, and ask the technician if the lengthy session can be divided into shorter sessions. Correct Explanation: Shorter sessions will allow the client to rest between the sessions. Changing the HCP's prescription to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent; thus it would not help this client avoid the adverse effects of a lengthy x-ray examination. Although the x-ray table is hard, it is not possible to provide padding and obtain the needed diagnostic x-rays

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next? a) Obtain new orders for the client from the physician on call. b) Ask the pharmacist for a list of preoperative medications for the client. c) Transcribe the preoperative medication orders the surgeon has ordered. d) Contact the surgeon for clarification because this is not a complete order.

Contact the surgeon for clarification because this is not a complete order. Correct Explanation: After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence.

Despite the presence of a large cohort of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. Which of the following should the nurses at the facility should recognize this as an example? a) Cultural imposition. b) Cultural assimilation. c) Stereotyping. d) Cultural blindness.

Cultural blindness. Correct Explanation: Cultural blindness is characterized by ignoring cultural differences or considerations and proceeding as if they do not exist. This phenomenon may underlie the failure to incorporate cultural considerations into dietary choices. Stereotyping assumes homogeneity of members of other cultures while cultural assimilation involves the replacement of values with those of a dominant culture. Cultural imposition presumes that everyone should conform to a majority belief system.

A client needs to be transferred to the oncology unit for further care. Which of the following information is necessary to include in the transfer report? a) Nursing treatment initiated. b) Results of laboratory tests. c) Current client assessment. d) Client's admission number.

Current client assessment. Correct Explanation: The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained. It is not important to mention the client's admission number during the transfer report. Information regarding the nursing treatment initiated and information about laboratory tests is important when reporting to the primary care provider and not in the transfer report

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order? a) Irrigation b) Debridement c) Incision and drainage d) Culture

Debridement Correct Explanation: Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture indentifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation — usually with an antibiotic solution — to treat the infection and clean the wound

The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which of the following functions? a) Clinical coordination b) Advocacy c) Networking d) Delegation

Delegation Explanation: The professional nurse is responsible for delegating routine nursing measures to non-licensed personnel. The nurse needs to make the decision as to which aspects can be delegated and which clients need to be assessed and cared for by professional nurses. The definitions of the other terms do not pertain to this situation

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? a) Demonstrating the procedure and having the client return the demonstration b) Writing out the instructions and having a family member read them to the client c) Asking frequently whether the client understands the instructions d) Asking an interpreter to relay the instructions to the client

Demonstrating the procedure and having the client return the demonstration Explanation: Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Asking whether the client understands the instructions isn't appropriate because clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit? a) Discuss alternative methods of having a family, such as adoption. b) Describe each of the potential causes and possible treatment modalities. c) Acknowledge that only 50% of infertile couples achieve a pregnancy. d) Choose an appropriate infertility treatment method.

Describe each of the potential causes and possible treatment modalities. Correct Explanation: By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for definitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are available to suggest that a specific treatment modality may not be successful. Suggesting that the couple consider adoption at this time may inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility.

A nurse is developing a care plan for a client who is a single parent. The client is experiencing anxiety after the loss of a job and is verbalizing concerns regarding the ability to meet role expectations and financial obligations. Which of the following is most important for the nurse to include in the plan of care? a) Explore the client's obsessive thoughts that are resulting in high anxiety. b) Determine the client's ability to cope with the job loss and family obligations. c) Ask the client about plans for managing the financial obligations. d) Interview family members to determine the dynamics of the family relationships.

Determine the client's ability to cope with the job loss and family obligations. Correct Explanation: The client is experiencing stressors that are making it difficult to cope, resulting in anxiety. It is important to assess the client's coping abilities related to the job loss and meeting family obligations. This situation could become a crisis if it overwhelms the client's usual methods of coping. The client is a single parent, which also adds the burden of childcare. The client is not concerned about the family dynamics or obsessive thoughts. Responding to the client's cues is vital in addressing the client's concerns.

A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality? a) Reading all information to the client before faxing b) Obtaining a written order from the client's primary physician to fax the information c) Making sure the client's name and date of birth are displayed on the fax cover sheet d) Determining that the client has authorized release of the information

Determining that the client has authorized release of the information Correct Explanation: A nurse must obtain client authorization before sending any confidential information to a nursing home or other facility. A client's name and other protected information should never appear on a fax cover sheet. It isn't necessary to read the information to the client before sending it. A physician's order doesn't give a nurse the right to send confidential information without the client's permission

When a nurse asks himself or herself questions such as "Why am I here?" the nurse is attempting to a) Develop a philosophical base for clearer thinking. b) Become a more spiritual being for other people. c) Strive toward unity with a higher power. d) Develop the concepts of holism and integration.

Develop a philosophical base for clearer thinking. Correct Explanation: In terms of spiritual care, your own background, family, culture, and religion are integral parts of interactions with clients. For this reason, taking a step back and examining your own spirituality, values, and beliefs is essential

A nurse-manager appropriately behaves as an autocrat in which situation? a) Identifying the strengths and weaknesses of a client-education video b) Directing staff activities if a client experiences a cardiac arrest c) Evaluating a new medication-administration process d) Planning vacation time for staff

Directing staff activities if a client experiences a cardiac arrest Correct Explanation: In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first? a) Complete an incident report. b) Notify the unit manager. c) Discuss the breach of practice with the physician. d) Ask the nurse educator to in-service the physician.

Discuss the breach of practice with the physician. Correct Explanation: The nurse should first discuss the breach of infection control procedures with the physician and discuss the practices that should be followed. The other options may be followed subsequently, but discussing with the physician is the first step.

A client tells the visiting community health nurse that another client's name and phone number were seen on the call display after the previous day's nurse used the client's home phone. What should the nurse do in response to this conversation? a) Discuss the matter with the other nurse, reminding him/her not to use the client's phone because it has a call display feature. b) Ask the client to visit the other client because he/she is lonely and would enjoy the company. c) Tell the client that the other client is on the nurse's list of clients, but do not disclose any further information. d) Tell the client that he/she should not be looking at the call display after the nurse leaves because it contains confidential information.

Discuss the matter with the other nurse, reminding him/her not to use the client's phone because it has a call display feature. Correct Explanation: Leaving personal information in view of other people is a breach of confidentiality. The nurse should approach the other nurse and inform him/her of the incident. The other options are incorrect because they do not protect the client's privacy and do not address the behavior of the other nurse.

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? a) Ask the client's spouse wife to hold the client's hands while the nurse puts the pill under the tongue. b) Emphasize the rationale for taking the medication now as ordered. c) Try to persuade the client to take the medication as ordered by the doctor. d) Document the client's choice and re-assess pain in 1 hour.

Document the client's choice and re-assess pain in 1 hour. Correct Explanation: A client has the right to choose whether to take medication. The nurse should assess the client's pain regularly and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication.

The client has been prescribed vaginal cream for a yeast infection to be administered via a vaginal applicator. In which position would the nurse instruct the client to take for appropriate administration? a) Low Fowler's position b) Supine position c) Sim's position d) Dorsal recumbent position

Dorsal recumbent position Explanation: The dorsal recumbent position (supine with the hips and knees bent) allows easy access to the vaginal orifice and proper placement for the medication. The other positions do not allow access to the vaginal orifice as the legs are closed.

Which of the following sounds should the nurse expect to hear when percussing a distended bladder? a) Tympany. b) Flatness. c) Hyperresonance. d) Dullness.

Dullness. Explanation: A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present

The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. What should the nurse do? a) Empty drainage. b) Remove the drain from the incision. c) Notify the surgeon. d) Record the amount in the unit as output on the client's medical record.

Empty drainage. Correct Explanation: Portable wound suction units can be emptied and drained. The nurse should compress the unit after emptying to create suction before reinserting the plug. It is normal for the suction unit to be full 6 hours after surgery, and the nurse does not need to notify the surgeon. The drainage unit should be emptied when full or every 8 hours. The drain in the incision should remain in place until the surgeon removes it. While all drainage should be noted as output on the medical record, recording the amount without emptying the drainage unit is not accurate nor is it safe practice.

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? a) Encourage foods high in vitamin B. b) Encourage a high-calorie, high-protein diet. c) Limit salt intake to 2 g per day. d) Restrict fluids to 1,500 ml per day.

Encourage a high-calorie, high-protein diet. Correct Explanation: The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? a) Turning the client every 2 hours b) Maintaining a cool room temperature c) Encouraging increased fluid intake d) Elevating the head of the bed 30 degrees

Encouraging increased fluid intake Correct Explanation: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions

A nurse who provides care on a post-surgical unit is performing discharge teaching as a component of her effort to ensure continuity of care. Which of the following is the primary goal of continuity of care? a) Controlling costs and maximizing client outcomes after discharge from the hospital. b) Minimizing nurses' legal liability during client transitions between healthcare institutions. c) Ensuring a smooth and safe transition between different healthcare settings. d) Increasing clients' knowledge base and health maintenance behaviors.

Ensuring a smooth and safe transition between different healthcare settings. Correct Explanation: Continuity of care exists primarily to ensure smooth, safe transitions so that clients may maximize recovery and health. Nurses build clients' knowledge bases to achieve this goal. Minimizing nurse liability and healthcare costs are not key justifications for continuity of care.

After completing a shift, a nurse realizes that documentation on a client was not completed before leaving the unit. Which of the following actions by the nurse is most appropriate? a) Call the unit, and dictate the entry to another nurse. b) Wait to hear if the nurse manager will offer some advice. c) Enter the information tomorrow stating it is a late entry. d) Call and ask the nurse to leave a blank entry for completion tomorrow.

Enter the information tomorrow stating it is a late entry. Correct Explanation: The nurse should enter the information on the medical record as a late entry with current date and time. The other options are incorrect because the nurse needs to document the care provided. Blank spaces should not be left in the chart and all care must be documented

Which would be most helpful when coaching a client to stop smoking? a) Review the negative effects of smoking on the body. b) Explain how smoking worsens high blood pressure. c) Discuss the effects of passive smoking on environmental pollution. d) Establish the client's daily smoking pattern.

Establish the client's daily smoking pattern. Correct Explanation: A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

The nurse is caring for an elderly nursing home client who is anxious and fearful after being admitted to the hospital. Which of the following interventions is the nursing priority? a) Explain procedures and unit routines to the client, as well as checking orientation. b) Ask what the fears are and why the client is becoming agitated. c) Have the client contact the family to come down to visit. d) Check on the client frequently to see the adjustment.

Explain procedures and unit routines to the client, as well as checking orientation. Correct Explanation: Explaining procedures and routines decreases the client's anxiety about the unknown. This is especially important to an elderly client who has been transferred from a familiar environment to a new one. Checking orientation gives feedback as to how the client is coping with the changes. Since there is fear and anxiety, it would be a challenge for the client to contact the family. "Why" questions tend to be judgmental and do not address the main concerns. Checking on the client is not sufficient; explanations will help ease the anxiety.

A 92-year-old is being discharged following a repair of an inguinal hernia. The client is independent and lives alone, and the client's family lives 60 miles from the client's house. When at home, the client is to cleanse and inspect the incision for signs of infection. The client and family are able to read and understand written instructions. When giving discharge instructions, what should the nurse do? Select all that apply. a) Give the family a link to a video showing the procedure. b) Explain the instructions to the client. c) Explain the instructions to a family member. d) Ask the client to demonstrate the procedure. e) Provide written instructions for the client.

Explain the instructions to the client. • Provide written instructions for the client. • Ask the client to demonstrate the procedure. Correct Explanation: The nurse should explain and demonstrate the discharge instructions and then ask the client to give a return demonstration. The Joint Commission and Health Canada require that discharge instructions be written for the postoperative client. Clients need to be given discharge instructions orally and in written form because of stress, medications, and the volume of material to be learned. Explaining all the instructions to a family member and giving them a link to a video is important but does not replace the need for written instructions. Since the family does not live nearby, the nurse must be certain the client can manage the instructions by herself

A child with leukemia had been in remission for several years, but death is now imminent. The nurse is assisting the parents as they prepare for the child's death. Which approach will be most helpful? a) Recognize that the parents have been prepared for this death since the time of diagnosis. b) Reflect to the parents that the death of a child is more difficult than that of an adult. c) Help parents understand that grief is stronger when preceded by hope. d) Understand the parent's trust in the health care system will be undermined by the death of their child.

Help parents understand that grief is stronger when preceded by hope. Correct Explanation: Parents often experience greater grief when they have experienced the hope provided by the remission of their child's disease. The nurse allows the parents to express this grief. Reactions to death of a family member are not based on the age of the dying family member. No matter how well prepared the parents may be for the death of their child, it will not make coping with death easier. Family members may displace anger and frustration on the health care system and health care providers (HCPs), but death does not necessarily undermine trust

What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness? a) Has your family been able to handle chronic illness management before? b) Does your family have the strength to deal with the changes and still support you through this difficult time? c) How is your condition affecting your family members and their usual roles? d) What is the best way your family resolves crisis situations?

How is your condition affecting your family members and their usual roles? Explanation: Clarification of the concerns the client has regarding the impact of the illness on the family is very important. This answer asks how members are affected. This is an important step before examining ways that the nurse might support the family during their period of adjustment. The other choices do not directly address the current situation and how the nurse can best assist the family

What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions? a) Apply negative pressure as the catheter is being inserted. b) Hyperoxygenate the client before suctioning. c) Deflate the cuff of the tracheotomy during suctioning. d) Instill acetylcysteine into the tracheotomy before suctioning.

Hyperoxygenate the client before suctioning. Correct Explanation: Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning. Deflating the cuff is not necessary and there is no reason to instill acetylcysteine into the tracheotomy before suctioning. Pressure is applied only with the removal of the catheter

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? a) Identifying salary ranges for various types of staff b) Identifying who will be responsible for making client care decisions c) Deciding what type of dress code will be implemented d) Determining how planned absences, such as vacation time, will be scheduled so that all staff are treated fairly

Identifying who will be responsible for making client care decisions Explanation: Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organizations, but they are not actually determined by the NCDS

The nurse works in an institution that expects nurses to initiate referrals to social or spiritual resources. What might trigger a nurse to initiate such a referral? Select all that apply. a) A client expressing a cultural concern. b) Impending death. c) A client requesting occupational therapy. d) A client requesting time alone. e) Family conferences

Impending death. • Family conferences. • A client expressing a cultural concern. Explanation: Results that might trigger a consult include clients and families expressing social, cultural, or spiritual concerns; death; receiving a terminal diagnosis; comfort care; family conferences; and crisis. A client requesting time alone or occupational therapy would not usually trigger a social or spiritual referral.

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? a) Laterally, from one side of the wound to the opposite side b) Laterally, from the distal area to the center c) From the superior portion of the wound to the inferior d) In a widening circle around the drain, outward from the center

In a widening circle around the drain, outward from the center Correct Explanation: When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from the superior portion of the wound to the inferior when cleaning a vertical incision. Cleaning the wound laterally from the distal area to the center increases the client's risk for infection

The nurse is preparing the room for a client diagnosed with Varicella. Identify which sign the nurse would place on the room door.

In addition to contact precautions, the nurse would place the client diagnosed with Varicella in airborne precautions. Airborne precautions include a facemask for the client/respirator for the nurse and personal protective equipment including gown and gloves. Droplet precautions are indicated for viruses, B. pertussis, group A streptococcus. Contact precautions are indicated anytime a nurse may come in contact with any body fluids

Which strategy can help make the nurse a more effective teacher? a) Using technical terms b) Including the client in the discussion c) Providing detailed explanations d) Using loosely structured teaching sessions

Including the client in the discussion Correct Explanation: An effective teacher always involves the client in the discussion. Using technical terms and providing detailed explanations usually confuse the client and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from teaching goals.

A client's spouse has arrived prior to surgery. When the client is transferred to the operating room, what would be appropriate for the nurse to tell the spouse? a) Encourage the spouse to go to work and come back later in the evening when the anesthetic effects are gone. b) Take this opportunity to discuss the concerns the client expressed regarding the implications this surgery has for the client's family. c) Inform the spouse that the client will be going to the recovery room after the operation, and that someone will notify the unit when the client is ready to come back. d) Inform the spouse that he/she can see the client as soon as he/she comes out of the operating room.

Inform the spouse that the client will be going to the recovery room after the operation, and that someone will notify the unit when the client is ready to come back. Correct Explanation: Informing the spouse of what to expect will allay apprehension. He/she can phone the unit and check for the client's return. Encouraging the spouse to go to work is not supportive. The client would be in recovery after the operating room, so the spouse might not be able to see the client immediately after surgery. A discussion about concerns should occur with the client as well

The nurse is planning care for a client with a Cantor tube. Which nursing measures should be included in the care plan? Select all that apply. a) Inject 10 mL of air into the tube to facilitate drainage. b) Coil extra tubing on the client's bed. c) Apply a water-soluble lubricant to the client's nares. d) Irrigate the tube with 50 mL of normal saline solution every 8 hours. e) Provide mouth care as needed.

Inject 10 mL of air into the tube to facilitate drainage. • Apply a water-soluble lubricant to the client's nares. • Coil extra tubing on the client's bed. • Provide mouth care as needed. Explanation: The nurse should provide mouth care as needed and apply a water-soluble lubricant to the nares. Extra tubing can be coiled to prevent kinking. The tube can be injected with air. Intestinal tubes are not irrigated.

An HIV-positive client discovers that his name is published in a report on HIV care prepared by his nurse. He strongly opposes this and files a lawsuit against the nurse. Which of the following offenses has this nurse committed? a) Unintentional tort. b) Invasion of privacy. c) Defamation. d) Negligence of duty.

Invasion of privacy. Correct Explanation: The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation, and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.

The nurse is obtaining a health history from a client of Puerto Rican descent. Which of the following is most likely to be a health problem with a cultural connection for this client? a) Suicide. b) Tuberculosis. c) Lactose enzyme deficiency. d) Sickle-cell anemia.

Lactose enzyme deficiency. Correct Explanation: Common health problems that may affect the Puerto Rican population include lactose enzyme deficiency and parasitic diseases. Tuberculosis is a common health problem for the Native American population. Sickle-cell anemia predominantly affects the African-American population, and suicide is a common health problem for the Native American and white middle-class populations

Which of the following involves charting information about the client and client care in chronological order? a) SOAP charting. b) PIE charting. c) Focus charting. d) Narrative charting.

Narrative charting. Correct Explanation: Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation

During a physical examination, a nurse asks a client to hold his breath briefly, and then uses a stethoscope to auscultate over his carotid arteries. Which finding is normal when auscultating over these arteries? a) No sounds over either carotid artery b) Throbbing pulsations bilaterally c) Louder sounds over the right carotid artery than over the left carotid artery d) Faint swishing sounds over both carotid arteries

No sounds over either carotid artery Explanation: Absence of sounds over either carotid artery indicates unobstructed blood flow. Auscultation of any sounds (bruits) is abnormal and the nurse should report this finding to the physician.

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following? a) Informed consent b) Pro-choice c) Nonmaleficence d) Self-determination

Nonmaleficence Explanation: Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? a) Simple mask b) Nasal cannula c) Nonrebreather mask d) Venturi mask

Nonrebreather mask Explanation: A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which of the following actions should the nurse take? a) Inform the physician about the living will. b) State that the physician will be a witness. c) Arrange for other colleagues to sign as a witness. d) Note that the nurse caring for the client cannot be a witness.

Note that the nurse caring for the client cannot be a witness. Explanation: A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate the reason for declining. Calling for a physician or asking another colleague to sign is an inappropriate action.

The nurse notices that the client's temperature over the past 24 hours has risen from 98.8°F (37.1°C) to 101.6°F (38.7° C). The nurse completes a head to toe assessment and documents the nurse's note. What would be the nurse's next nursing action? a) Obtain a urine culture b) Apply oxygen at 2 liters per nasal cannula c) Notify the healthcare provider d) Pass on the data to the next shift

Notify the healthcare provider Correct Explanation: When the nurse notes a significant rise in temperature to a febrile status, the nurse must first complete a head to toe assessment to obtain all client data and then notify the health care provider. The health care provider may then opt to assess the client or order diagnostic studies to determine a reason for the rise in client temperature. The nurse would pass the data on to the next shift; however, only the health care provider can order diagnostic testing. Early identification of a problem can lead to subsequent treatment. There is no data that the client is short of breath or oxygen compromised that oxygen needs applied. The nurse would not complete a urine culture without a health care provider's order.

A client has signed a document indicating a wish not to be resuscitated. During morning rounds, the nurse finds the client without vital signs. What is the most appropriate action for the nurse to take? a) Begin CPR until the family can be notified. b) Review the client's chart to verify resuscitation status. c) Call the supervisor for further directions. d) Notify the physician that the client has no vital signs.

Notify the physician that the client has no vital signs. Correct Explanation: The resident has signed a document indicating the client's wish not to be resuscitated. The other options are incorrect because the nurse should be aware of the client's "do not resuscitate" (DNR) status and should not need to go to the desk to confirm this. The nurse should notify the physician so he/she can pronounce the death and notify the family.

A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do first? a) Notify the physician. b) Call a security guard to help detain the client. c) Have the client sign an AMA form. d) Prevent the client from leaving.

Notify the physician. Correct Explanation: If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left

Which of the following is the recommended nursing assessment to confirm placement of the nasogastric (NG) tube into the stomach of a client? a) NG tube length is equal to the distance from the client's ear lobe to the nose, plus the distance from the nose to the tip of the xiphoid process; this will confirm correct placement. b) Obtain a chest X-ray and measure the pH of stomach contents. c) Measure to the second or third black marking on the NG tube. d) Apply the stethoscope to the xiphoid process and instill 50 mL of air into the tube and listen for a gurgling or popping sound.

Obtain a chest X-ray and measure the pH of stomach contents. Correct Explanation: A chest X-ray and pH that shows acidity are the only definitive diagnostic tools to confirm placement. The other choices are not best practice. Measuring the tube or using makings do not confirm placement, only approximate distance for insertion

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate? a) Divert the client's attention by turning on the television. b) Offer ice chips every hour to decrease thirst. c) Offer the client frequent oral hygiene care. d) Reexplain to the client why she cannot drink.

Offer the client frequent oral hygiene care. Correct Explanation: The most appropriate intervention is to offer the client frequent mouth care to moisten the dry oral mucosa. Reexplaining why the client cannot drink may be helpful but will not relieve the thirst. Ice chips cannot be given to a client who is on NPO status. Diverting the client's attention does not help manage the thirst

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema? a) A heart rate of 88 beats/minute b) Dry and intact wound dressing c) Oral temperature of 101° F (38.3° C) d) Wound healing by primary intention

Oral temperature of 101° F (38.3° C) Correct Explanation: The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? a) QRS complex b) T wave c) P wave d) PR interval

P wave Explanation: The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization

A client returned from surgery eight hours ago and has not voided. Which action should the nurse take first? a) Catheterize the client with a straight catheter. b) Call the physician to report the client's condition. c) Palpate over the synthesis pubis for fullness. d) Tell the client to bear down and try to void.

Palpate over the synthesis pubis for fullness. Explanation: Before taking any action, the nurse must palpate over the client's synthesis pubis. If the client's is retaining urine there will be fullness over the bladder. Urine retention is a common adverse effect of anesthesia. After confirming retention, the nurse should call the physician and expect an order to catheterize the client. Telling the client to bear down and try to void is inappropriate

Why should the nurse avoid palpating both carotid arteries at one time? a) Palpating both arteries at one time may cause severe tachycardia. b) Palpating both arteries at one time may cause severe bradycardia. c) Palpating both arteries at one time may cause transient hypertension. d) The nurse can't assess the pulse accurately unless she palpates the arteries one at a time.

Palpating both arteries at one time may cause severe bradycardia. Explanation: The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

What should the nurse do to prevent pressure ulcers in an older adult? a) Clean the skin daily using mild soap and hot water. b) Encourage the client to sit in a chair as much as possible. c) Perform a systematic skin assessment at least once a day. d) Massage bony prominences gently every shift.

Perform a systematic skin assessment at least once a day. Correct Explanation: Daily skin inspection is essential in preventing pressure ulcers. Hot water is irritating to skin and should be avoided. Massaging bony prominences is contraindicated and may actually promote skin breakdown. Prolonged, uninterrupted chair sitting should be avoided; the client's position should be adjusted at least every hour.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? a) Set up a conference with the parents of each child to explain the situation carefully. b) Restrict the infected children from returning for 48 hours after treatment. c) Close the day care center for 1 week to control the outbreak. d) Perform thorough hand washing before and after touching any child in the day care center.

Perform thorough hand washing before and after touching any child in the day care center. Correct Explanation: Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection

Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed? a) Position the client on his or her side for 5 minutes. b) Administer a prescribed analgesic 10 minutes prior to getting out of bed. c) Have the client flex and extend the feet while in a recumbent position. d) Place the client in a high Fowler's position.

Place the client in a high Fowler's position. Correct Explanation: Many clients feel faint and weak when helped to ambulate for the first time after surgery. The client's circulatory system needs time to adjust to an upright position before the client is helped to a standing position. This is best done by placing the client in high Fowler's position in bed for a few minutes. After becoming accustomed to a sitting position, the client can then be helped to dangle the feet at the edge of the bed before ambulating. Although analgesics can promote comfort for the postoperative client, some can sedate the client and should not be given at the time the client is assisted out of bed. Having the client lie on the side of the bed or do leg exercises will not prepare the client to dangle the legs.

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? a) Wearing gloves during all client contact b) Assessing the client's temperature every 8 hours c) Placing the client in respiratory isolation d) Monitoring the client's fluid intake and output

Placing the client in respiratory isolation Correct Explanation: Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances

A nurse assesses spirituality to gain an understanding of what in relation to the client's life? a) Common practices shared with a group b) Sense of meaning and purpose c) Possible coping mechanisms d) Meaning of afterlife

Possible coping mechanisms Explanation: Religion and spirituality have been related to a client's well-being when facing illness and disease. They can be powerful coping mechanisms when a client is facing life-or-death decisions. The definition of spirituality is a search for meaning and purpose in life. "Common practices shared by a group of people" is the definition of religion. Religion also helps to define the meaning of the afterlife

A client is experiencing considerable stress in a change of role from married to divorced. The client states that the in-laws blame the client's drinking for the divorce. The client states that, "These days, a couple of glasses of wine in the evenings helps calm my nerves." What is the best coping strategy for the nurse to offer the client? a) Use assertiveness training techniques. b) Rely on the support of work colleagues. c) Practice deep breathing and muscle relaxation. d) Cease all contact with the in-laws.

Practice deep breathing and muscle relaxation. Correct Explanation: The client is experiencing stress due to a role change subsequent to the recent divorce. Using previously learned relaxation techniques would be an appropriate way of decreasing stress without using alcohol as a temporary fix. Ceasing contact with significant others is extreme and would not be recommended. Similarly, suggestions to rely on work colleagues would not be appropriate. While assertiveness techniques may be helpful in the long term, short term stress is well managed with relaxation techniques

A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection? a) Proper nutrient intake b) Impairment of primary body system defenses c) Chronic disease d) Inadequate secondary defenses

Proper nutrient intake Explanation: Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)? a) Monitoring his temperature every 4 hours b) Covering the client with a light blanket c) Increasing fluid intake d) Providing a low-calorie diet

Providing a low-calorie diet Correct Explanation: Because a client with a fever has an increased basal metabolism rate, he needs additional calories in his diet, not fewer calories. Monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket are therapeutic interventions for a fever

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)? a) Monitoring his temperature every 4 hours b) Covering the client with a light blanket c) Increasing fluid intake d) Providing a low-calorie diet

Providing a low-calorie diet Correct Explanation: Because a client with a fever has an increased basal metabolism rate, he needs additional calories in his diet, not fewer calories. Monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket are therapeutic interventions for a fever.

A nurse arriving for duty notes that a nursing assistant (or unregulated care provider [UCP]) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UCP? a) Provide the UCP with a list of resources to guide the implementation of care. b) Reassign the UCP to a client requiring basic tasks that the UCP has mastered. c) Supervise the UCP during the treatments involving sterile technique. d) Make sure the UCP has practiced sterile technique on at least one other occasion.

Reassign the UCP to a client requiring basic tasks that the UCP has mastered. Explanation: The nurse is accountable for the delegation of tasks to UCPs. The nurse delegates tasks to UCPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UCPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UCP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UCP has the knowledge and skill to provide the care or carry out the task

A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action? a) Dividing revenue among stockholders as dividends b) Reducing operating expenses to help the organization pay taxes on the revenue c) Identifying revenue as profit d) Receiving a portion of the revenue to improve client services on the unit

Receiving a portion of the revenue to improve client services on the unit Correct Explanation: In a nonprofit organization, revenue exceeding expenses is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls revenue in excess of expenses a profit and divides it as a dividend among stockholders or reinvests it in the organization

A client with metastatic bone cancer has signed a Do Not Resuscitate (DNR) order. Which of the following would require the nurse to perform a re-evaluation of care? Select all that apply. a) Inability to breathe without intubation b) A request by family for antibiotic therapy to treat pneumonia c) Coughing up thick secretions with choking and episodes of apnea d) Requesting oral pain medication every hour e) Recommendation that a feeding tube be inserted due to difficulty swallowing

Recommendation that a feeding tube be inserted due to difficulty swallowing • A request by family for antibiotic therapy to treat pneumonia • Requesting oral pain medication every hour Explanation: Because the client has signed a DNR order, only comfort measures should be taken. Insertion of a feeding tube would be inappropriate because it would sustain life. Oral pain medications would not be sufficient to control the pain of end-stage bone cancer, thus a re-evaluation for a stronger method of control would be necessary. A request by family for antibiotic therapy to treat pneumonia does not honor the client's request. Coughing up thick secretions with choking episodes of apnea and inability to breathe without intubation would be expected outcomes and, although difficult, comfort measures as requested by the client should prevai

Which of the following statements about religion and spirituality is most accurate? a) Religion and spirituality are synonymous. b) Religion is an organized system of spiritual beliefs. c) Spirituality is a recently developed alternative to traditional religious belief. d) Spirituality is the behavioral manifestation of religious beliefs.

Religion is an organized system of spiritual beliefs. Correct Explanation: Spirituality may or may not include religion, which is a codified system of spiritual beliefs. The two terms are not interchangeable, and spirituality is not solely concerned with outward behavior. Spirituality is not necessarily an "alternative" to religion, nor is it a recent development

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. a) Call the health care provider (HCP) for a temperature above 100° F (37.8° C). b) Wear sterile gloves to change the fluids. c) Report signs of redness or inflammation at the site. d) Cleanse the port with alcohol wipes. e) Place the IV bag on a table level with the client's arm.

Report signs of redness or inflammation at the site. • Cleanse the port with alcohol wipes. • Call the health care provider (HCP) for a temperature above 100° F (37.8° C). Correct Explanation: 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.

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: a) Document the bruising and continue to assess the area over the next 72 hours. b) Report this finding to the physician. c) Report this finding to the Adult Protective Services (APS). d) Report this finding to the nurse who is taking care of the client.

Report this finding to the Adult Protective Services (APS). Explanation: Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS

A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal? a) Keeping the head of the bed at a 30-degree angle b) Administering oxygen by nasal cannula as ordered c) Restricting fluids to 1,000 ml/24 hours d) Repositioning the client every 2 hours

Repositioning the client every 2 hours Correct Explanation: Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected? a) Respecting the client's desire to have the uncle make choices on her behalf. b) Teaching the client about her right to autonomy. c) Revisiting the decision when the uncle is not present at the bedside. d) Holding a family meeting and encouraging the client to speak on her own behalf.

Respecting the client's desire to have the uncle make choices on her behalf. Explanation: The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners? a) Physical therapist. b) Physician. c) Occupational therapist. d) Respiratory therapist.

Respiratory therapist. Correct Explanation: A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in forgoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely to provide needed interventions at this time.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? a) PIE charting. b) Narrative charting. c) SOAP charting. d) Focus charting.

SOAP charting. Correct Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation

The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. Which nursing diagnosis is most appropriate? a) Spiritual distress b) Chronic sorrow c) Ineffective coping d) Complicated grieving

Spiritual distress Correct Explanation: The defining characteristic of Spiritual distress includes anger and refusing to interact with spiritual leaders. While anger is part of the grieving process, there's no indication that the parents aren't coping effectively or experiencing Complicated grieving. Since Chronic sorrow, as the name implies, occurs over a period of time and may be cyclical, this isn't an appropriate nursing diagnosis since the death has just occurred.

A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply. a) Strong, bounding pulses b) Skin temperature changes c) Edema d) Normal sensation e) Skin discoloration f) Skin pink in color

Skin discoloration • Edema • Skin temperature changes Correct Explanation: Lack of oxygen to nourish tissues at the capillary level causes edema, discoloration, and changes in skin temperature. Pulses will be weak or absent, and the client will experience altered sensation. Pink skin color; strong, bounding pulses; and normal sensation are signs of adequate perfusion

A nurse is counseling a client with cancer who is experiencing anxiety. Which goal will provide the best long-term client outcome? a) Keep follow-up appointments with psychiatrists. b) Understand medication effects and adverse effects. c) Solve problems independently. d) Take medication as prescribed.

Solve problems independently. Explanation: The ultimate outcome is to have the client solve problems by himself, collaborating in his own care. Client follow-up with the mental health providers, while desirable, does not ensure that the client will fully comply with treatment or medication. Knowledge of the medication's effects and adverse effects and compliance can help the client but alone will not ensure success unless the client knows how to address and solve problems independently.

An appropriate nursing diagnosis for a bedridden and hospitalized client who tells the nurse that he is upset because he has not missed a Methodist church service in 50 years is a) Spiritual need as evidenced by verbalization and distress at missing Methodist church services. b) Spiritual distress related to inability to attend church services evidenced by verbal states of guilt. c) Potential for enhanced spiritual well-being related to distress at missing Methodist church services. d) Dysfunctional grieving related to inability to attend church services as a result of his medical condition.

Spiritual distress related to inability to attend church services evidenced by verbal states of guilt. Correct Explanation: People with spiritual dysfunction or distress may verbalize such distress or express a need for help.

When providing care to Aboriginal clients, it may be important for the nurse to elicit help from the a) Priestess. b) Preacher. c) Rabbi. d) Spiritual healer.

Spiritual healer. Correct Explanation: Shamans and spiritual leaders are found among Aboriginal and many Southeast Asian groups.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? a) Change the feeding container daily. b) Place the client in semi-Fowler's position while feeding. c) Give the feedings at room temperature. d) Stop the feedings and check for residual volume.

Stop the feedings and check for residual volume. Correct Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth

A client at a mental health clinic who has recently emigrated from another country identifies isolation and loneliness as current stressors. The client describes being withdrawn but does not know how to change the situation. Which of the following is the most appropriate step for the nurse to take to help the client? a) Refer the client to special interest clubs for newcomers. b) Model culturally appropriate interactional skills. c) Support the client in developing attainable socialization goals. d) Have the client plan a social activity for the upcoming weekend.

Supporting the client in goal-setting around social interaction is the first step in promoting change for wellness. Merely referring a client to a social activity is only a short-term solution, and may not be an intervention desired by the client. Modeling is important; however, interactional skills are individualized and must be authentic to be successful for the client. Suggesting solutions such as planning a specific activity with anyone is not appropriate to social wellness

When preparing for a spiritual counselor to visit a hospitalized patient, the nurse should: a) Ask the spiritual counselor to summarize the visit in the patient's medical record. b) Ensure that the the hospital administration approves the counselor. c) Ask to be present during the visit to explain any medical information or answer questions about the patient's care. d) Take measures to ensure privacy during the counselor's visit.

Take measures to ensure privacy during the counselor's visit. Correct Explanation: Visits between a patient and a spiritual counselor require privacy. The details of the meeting are not typically documented in the patient's chart, though the fact that the visit took place is often noted. The nurse may be present during the meeting, but this should take place at the patient's request. Spiritual counselors do not require administrative approval; patients and their families are normally able to seek spiritual help from whomever they prefer

A nurse is giving a presentation to retirement home residents on fall prevention and injury reduction. Which of the following would be the most important priority? a) Discussion of instability and effective use of ambulatory aids to stabilize the base of support b) Discussion about decreasing activity and favoring the use of wheelchairs, rather than mobility aids, to reduce the incidence of falls c) Explanation of the importance of a health professional evaluating gait and assessing for motor deficits d) Teaching about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness

Teaching about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness Explanation: Sitting for a few minutes is the most appropriate to discuss to help maintain safety and reduce falls. Reliance on wheelchairs rather than mobility aids will result in weakening of the muscles and less strength and stability. The remaining actions would be important factors but not the immediate priority.

The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. Then nurse informs the parents that the development of a child's spirituality is best accomplished by: a) Teaching the child about religion. b) Teaching through religious-based schools. c) Teaching through parental behaviors. d) Teaching the child about God.

Teaching through parental behaviors. Correct Explanation: A child's parents play a key role in the development of the child's spirituality. What is important is not so much what parents teach a child about God and religion, but rather what the child learns about God, life, and self from the parent's behavior.

A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain? a) Occipital b) Frontal c) Temporal d) Parietal

Temporal Correct Explanation: The temporal lobe controls hearing, language comprehension, and storage and recall memory. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The occipital lobe functions primarily in interpreting visual stimuli. The parietal lobe interprets and integrates sensations, including pain, temperature, and touch.

The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the health care provider (HCP)? a) The child reports having a previous surgery for a ruptured appendix. b) The family lives a long distance from the medical facility. c) The family feels the child cannot self-regulate to wake at night and change bags. d) The child attends a large public school.

The child reports having a previous surgery for a ruptured appendix. Explanation: A client who has had a ruptured appendix may have peritoneal scarring that may alter the effectiveness of treatment. Living a long distance from a medical facility is typically a reason to select peritoneal dialysis. Attending a large school is not a problem, but the school nurse needs to be included as part of the health care team. Typically the treatment schedule can be planned to allow for uninterrupted sleep at night.

When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which outcome indicates that the client is following instructions? a) The skin around the stoma is red. b) The seal around the stoma is intact. c) There is no odor present. d) The urine is a deep yellow.

The seal around the stoma is intact. Correct Explanation: If the appliance becomes too full, it is likely to pull away from the skin completely or to leak urine onto the skin; thus if the seal is intact, the client is emptying the appliance regularly. The skin around the seal should not be red or irritated, which could indicate a leak. There will likely be an odor from the urine. Deep yellow urine indicates that the client should be increasing fluid intake

When the client tells the nurse that she believes that God's reality is personal and that God is the creator of all beings, the nurse determines the client is expressing a) Faith. b) Agnosticism. c) Atheism. d) Theism.

Theism. Explanation: Theism is the belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? a) The client rinses around the clean incision site, using gauze squares moistened with tap water. b) The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. c) After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing. d) The client rinses around the clean incision site, using gauze squares moistened with normal saline.

To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline — not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of nonraveling material instead of cotton-filled gauze squares.

A client reports for a preoperative appointment in preparation for surgery that will change his body from female to male. The client has expressed to the nurse and physician that she should have been born a man. What identity is the client demonstrating? a) Transsexual. b) Bisexual. c) Transvestite. d) Homosexual.

Transsexual. Explanation: A transsexual is a person of a certain biologic gender who has the feelings of the opposite sex and of being trapped 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 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis? a) Tripod position b) Clear speech c) Mild fever d) Gradual onset of symptoms

Tripod position Correct Explanation: The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing. Epiglottitis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling

An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? a) Use a nightlight in the bathroom. b) Place the client in a room with a camera monitor. c) Keep all four side rails up at all times. d)

Use a nightlight in the bathroom. Correct Explanation: Many falls occur when older clients attempt to get to the bathroom at night. The risk is even greater in an unfamiliar environment. Use of a nightlight in the bathroom enables the older adult client to see the way to the bathroom. Keeping the lights on in the room at all times may contribute to sensory overload and prevent adequate rest. Raised side rails paradoxically contribute to falls when the older client tries to climb over them to get to the bathroom. The upper side rails may be raised, but it is not recommended that all four side rails be elevated. Camera monitoring can be used but does nothing to prevent a fall.

The nurse instructs the unlicensed assistive personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which technique should the nurse ask the UAP to incorporate into the client's daily care? a) Use a soft toothbrush to brush the client's teeth after each meal. b) Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours. c) Rinse the client's mouth with mouthwash several times a day. d) Assess the oral cavity each time mouth care is given and record observations.

Use a soft toothbrush to brush the client's teeth after each meal. Correct Explanation: A soft toothbrush should be used to brush the client's teeth after every meal and more often as needed. Mechanical cleaning is necessary to maintain oral health, stimulate gingiva, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the UAP. Swabbing with a safe foam applicator does not provide enough friction to clean the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use.

The nurse is working in the intensive care unit with a client in shock. During hand-off the nurse reports the results of which assessment findings that signal early signs of the decompensation stage? Select all that apply. a) Peripheral pulses b) Skin color c) Nutrition d) Gait e) Vital signs f) Urine output

Vital signs • Skin color • Urine output • Peripheral pulses Explanation: Shock is a medical emergency in which the organs and tissues of the body are not receiving adequate blood flow. Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys and peripheral pulses all provide assessment data relating blood volume and circulation. Nutrition and gait is not related to blood circulation

A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is prescribed, but the mother will not sign the consent until the father arrives to give permission. What should the nurse do? a) Report this to the social worker. b) Call the regional protective services for children. c) Wait until the father arrives. d) Inform the health care provider (HCP) that the mother has refused to have the procedure.

Wait until the father arrives. Correct Explanation: In the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission. It is not necessary to contact the social worker at this point. The client has not refused the procedure, so it is premature to contact the HCP. This is not a situation of suspected child abuse

The nurse has completed discharge teaching with new parents who will be bottle-feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? a) "Our baby will require feedings through the night for several weeks or months after birth." b) "The baby should burp during and after each feeding with no projective vomiting." c) "Our baby should have 1 to 3 soft, formed stools a day." d) "We should weigh our baby daily to make sure he is gaining weight."

We should weigh our baby daily to make sure he is gaining weight." Correct Explanation: Healthy infants are weighed during their visits to their health care provider (HCP) , so it is not necessary to monitor weights at home. Infants may require 1 to 3 feedings during the night initially. By 3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis and should not be seen in a normal newborn. Bottle-fed infants may stool 1 to 3 times daily

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? a) Rectal b) Tympanic c) Axillary d) Oral

When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder

Under which circumstance may a nurse communicate medical information without the client's consent? a) when certifying the client's absence from work b) when requested by the client's family c) when prescribed by another health care provider (HCP) d) wWhen treating the client with a sexually transmitted disease

When treating the client with a sexually transmitted disease Explanation: Sexually transmitted infections are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency and to otherwise maintain the client's confidentiality. The client's family cannot request release of medical information without the client's consent. A HCP's prescription is not a substitute for a client's consent to release medical information in the absence of a communicable disease.

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first? a) a 52-year-old with pneumonia and chronic back pain who is requesting pain medication b) a 38-year-old who is 2 days postmastectomy due to breast cancer, having difficulty coping with the diagnosis c) an 84-year-old with resolving left-sided weakness who is slightly confused and has been awake most of the night d) a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours

a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours Explanation: Urine output should be at least 500 mL in 24 hours (20 mL/h); this client's output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further determine her needs.

The nurse is planning to complete assessments during the last half hour of the shift. Which assessment should be accomplished first? a) a postpartum couplet with the infant who has had transient tachypnea of the newborn (TTN) at birth and now has a respiratory rate of 60 breaths/minute b) a mother who had a cesarean section and is 6 hours after birth with the baby in special care nursery; the mother has not yet seen her baby c) a newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour initiated 10 hours ago for preeclampsia; her infant ate poorly previously and has not eaten for 4 hours d) a couplet with baby born at 36 weeks' gestation; the 5-lb (2,268-g) infant had initial blood glucose of 35 mg/dL (1.9 mmol/L) and when taken to the room had a glucose of 46 mg/dL (2.6 mmol/L)

a newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour initiated 10 hours ago for preeclampsia; her infant ate poorly previously and has not eaten for 4 hours Explanation: The infant who has not eaten in 4 hours is the highest priority of this group of couplets. The last feeding was 4 hours ago, and the prior poor feeding puts this infant at risk. An assessment of this infant is needed from a safety perspective since the mother had magnesium sulfate. The nurse should question whether the poor feeding may be a result of magnesium sulfate in the newborn's system by evaluating respiratory rate, tone, and current ability to feed. The couplet with an infant with TTN and a respiratory rate of 60 is within normal limits but should have the respiratory rate reevaluated to assure normalcy. The mother who had a cesarean section should be evaluated to determine when she will be able to go to SCN to see her infant. Urgency concerning taking her to the nursery will also depend on the condition of the newborn. The newborn of 36 weeks' gestation is currently within normal blood glucose range, but would need to be monitored frequently because of the small infant size and prior low blood glucose.

A nurse should question an order for a heating pad for a client who has: a) active bleeding. b) a reddened abscess. c) an edematous lower leg. d) purulent wound drainage.

active bleeding. Explanation: Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." The nurse should: a) allow the client to see and hold the baby for as long as she desires. b) contact the primary care provider for advice related to the client's visitation. c) tell the client that it would be best if she did not see the baby. d) allow the client to see the baby through the nursery window.

allow the client to see and hold the baby for as long as she desires. Correct Explanation: The nurse should allow the client to see and hold the baby for as long as she desires. Such activities provide memories for the mother and assist in the grieving process. There is a possibility that the client may change her mind about the adoption. If the client changes her mind about the adoption, the nurse should accept the client's decision and notify the primary care provider and social worker. Telling the client that it would be best if she did not see the baby is imposing the nurse's value system on the client. Allowing the client to see the baby through the nursery window is inappropriate because the client should be allowed to touch and hold the baby. Contacting the primary care provider for advice related to the client's visitation is not necessary.

Which client is most at risk for potential hazards from the surgical experience? a) an 80-year-old client b) a 30-year-old client c) a 15-year-old client d) a 50-year-old client

an 80-year-old client Correct Explanation: The 80-year-old client is at greater risk because an older adult client is more likely to have comorbid conditions, a less-effective immune system, and less collagen in the integumentary system.

A multipara gives birth to a neonate at 24 weeks' gestation. After 12 hours, the neonate's condition deteriorates, and death appears likely within the next few minutes. The parents are Roman Catholic, and they request that the neonate be baptized. The nurse should: a) contact the hospital chaplain to perform the baptism. b) baptize the neonate, regardless of the nurse's own religious beliefs. c) alert the hospital's director that a neonatal death is imminent. d) find a health care provider who is Roman Catholic to perform the baptism

baptize the neonate, regardless of the nurse's own religious beliefs. Explanation: Tenets of the Roman Catholic Church hold that it is acceptable for anyone, regardless of his or her religious beliefs, to baptize a neonate. For Roman Catholic families, baptism ensures entry into heaven. Local practice may vary, and in some situations, the parents may prefer to have a Roman Catholic person perform the rites; however, the priest may not be available until after the death. The parents may wish to have a priest contacted for grief support. Notification of the hospital's director is not necessary.

A primiparous woman has recently given birth to a term infant. Priority teaching for the patient includes information on: a) infant bathing. b) infant sleep-wake cycles. c) breastfeeding. d) sudden infant death syndrome (SIDS).

breastfeeding. Correct Explanation: Breastfed infants should eat within the first hour of life and approximately every 2 to 3 hours. Successful breastfeeding will likely require sustained support, encouragement, and instruction from the nurse. Information on SIDS, infant bathing, and sleep-wake cycles are also important topics for the new parent, but can be done at any time prior to discharge.

A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which nutrient is most helpful for promoting endurance during sustained activity? a) carbohydrate b) fat c) water d) protein

carbohydrate Correct Explanation: The stored glucose of muscle glycogen is the major fuel during sustained activity. Glucose production slows as the body begins to depend on fat stores for glucose and fatty acids. Protein is not the body's preferred energy source. Fat is a secondary source of energy. Water is not an energy source, although sufficient water is required to engage in aerobic activity without causing dehydration.

The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. The nurse should: a) rate the client on the Glasgow Coma Scale. b) call the surgeon. c) administer oxygen. d) check the client's baseline data.

check the client's baseline data. Correct Explanation: The nurse should check the client's baseline data to ascertain whether the client's pupil has always been enlarged or this is a new finding. The preoperative assessment is valuable as the baseline for comparison of all subsequent assessments made throughout the perioperative period. The nurse may determine that a more involved neurologic examination is indicated or may choose to assess other signs using the Glasgow Coma Scale, administer oxygen, or call the surgeon, but the nurse still needs to know the baseline data before proceeding

The surgical floor receives a new postoperative client from the postanesthesia care unit. Assessment reveals that the client has a patent airway and stable vital signs. The client's pain level was 2. The nurse should next: a) check the dressing for signs of bleeding. b) determine if the client has a full bladder. c) empty any peri-incisional drains. d) reassess the client's pain level.

check the dressing for signs of bleeding. Explanation: The nurse should check the dressing for signs of bleeding to establish a baseline for future assessments of the dressing and to verify that there is no obvious sign of hemorrhage. The nurse does not need to empty peri-incisional drains at this time. All drains should have been emptied and reconstituted by the postanesthesia care nurse before the client was transferred to the surgical floor. Assessing the client's pain level and assessing the bladder are important; however, it is more important to assess the surgical site for bleeding because hemorrhage is a life-threatening complication of any surgical procedure

When auscultating a client's chest, a nurse assesses a second heart sound (S2). This sound results from: a) closing of the mitral and tricuspid valves. b) opening of the aortic and pulmonic valves. c) closing of the aortic and pulmonic valves. d) opening of the mitral and tricuspid valves

closing of the aortic and pulmonic valves. Explanation: The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. The nurse should: a) notify the health care provider (HCP). b) ask another nurse to validate the absence of bowel sounds. c) encourage the client to take more ice chips. d) document assessment findings in the client's medical record.

document assessment findings in the client's medical record. Correct Explanation: Bowel sounds are not present until the third or fourth postoperative day; the nurse should document the assessment findings. Too many ice chips may promote abdominal distention, especially if the client is not ambulating in the intermediate postoperative period

While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which is believed to be the most distressing fear a preoperative client is likely to experience? a) fear of being in pain b) fear of the unknown c) fear of changes in body image d) fear of the effects of anesthesia

fear of the unknown Correct Explanation: Anxiety in a preoperative client may be caused by many different fears, such as fear of the effects of anesthesia, the effects of surgery on body image, separation from family and friends, job loss, disability, pain, or death. However, fear of the unknown is most likely to be the greatest fear because the client feels helpless. Therefore, an important part of preoperative nursing care is to assess the client for anxieties and explore possible causes. Emotional support can then be offered so that the client is in the best possible psychological condition for surgery.

A hospitalized client is experiencing a "fight-versus-flight," a stress-mediated physiologic response. As a result, the nurse should assess the client for: a) decreased mental acuity. b) increased urinary output. c) increased blood glucose. d) decreased arterial blood pressure.

increased blood glucose. Correct Explanation: Responses to physiologic stress, such as hospitalization, surgery, or pain, are a result of catecholamine release, and specifically include increased heart rate and blood pressure, increased bronchiolar dilation, water retention and decreased urinary output, increased blood glucose, and increased mental acuity.

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect: a) inspiratory and expiratory wheezing. b) increased forced expiratory volume. c) normal breath sounds. d) morning headaches.

inspiratory and expiratory wheezing. Correct Explanation: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume (forced expiratory flow [FEF] is the flow [or speed] of air coming out of the lung during the middle portion of a forced expiration) due to bronchial constriction. Morning headaches are found in more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.

A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. The nurse should: a) inform the UAP that massage is even more effective when combined with the use of lotion. b) instruct the UAP that massage is contraindicated because it decreases blood flow to the area. c) explain to the UAP that massage is effective because it improves blood flow to the area. d) reinforce the UAP's use of this intervention over the bony prominence.

instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Correct Explanation: Massaging an area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing pressure ulcer formation.

When planning a culturally sensitive health education program, the nurse should: a) locate the program at a facility that will not charge for use. b) prepare materials in the primary language of the program sponsor. c) integrate folk beliefs and traditions into the content. d) exclude community leaders from the dominant culture from initial planning efforts.

integrate folk beliefs and traditions into the content. Correct Explanation: Strategies to reach clients in all cultures should include incorporating the folk beliefs and traditions of the target population into the program. Identification of a centrally located building with available access by the target population, use of materials in the native or primary language of the target population, and involvement by all community leaders will also help the program succeed.

When a client has a tearing of tissue with irregular wound edges, the nurse should document this as: a) colonization. b) contusion. c) laceration. d) abrasion.

laceration. Correct Explanation: The nurse should document a tearing of tissue with irregular wound edges as a laceration. A contusion or a bruise is a closed wound caused by a blunt object resulting in bleeding in underlying tissue. An abrasion is a superficial wound from a rubbing or a scraping of the surface of the skin such as from a fall. Colonization is a wound containing microorganisms.

The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration? a) orthostatic hypotension b) moist crackles c) bounding pulse d) shortness of breath

orthostatic hypotension Correct Explanation: Orthostatic hypotension or persistent hypotension is present in dehydration, as are poor skin turgor, dry oral mucous membranes, and tachycardia. If the dehydration is severe, the client may also be restless, confused, and thirsty. Most instances of crackles is indicative of excess fluid volume, not dehydration. Shortness of breath or a bounding pulse may be indicative of excess fluid, not dehydration.

A client is admitted for an arthroscopy of the right shoulder through same-day surgery. Which nurse is responsible for starting the client's discharge planning? a) preoperative nurse b) preadmission nurse c) intraoperative nurse d) postoperative nurse

preadmission nurse Explanation: The preadmission nurse, the first person in contact with the client, starts the discharge planning for the client undergoing surgery. All nurses involved with the client, from preadmission through postoperative recovery, should continue to reinforce the discharge pla

When percussing a client's chest, the nurse should expect to hear: a) tympany. b) dullness. c) hyperresonance. d) resonance.

resonance. Correct Explanation: Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.

An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms? a) urine specific gravity b) serum osmolality c) platelet count d) serum sodium

serum sodium Explanation: This client is exhibiting behaviors and symptoms associated with hyponatremia caused by water intoxication; the nurse would expect to find confirmation of a low serum sodium level by checking the electrolyte levels. The nurse would expect this client's serum osmolality and urine specific gravity to be low, not high.

The nurse uses Montgomery straps primarily so the client is free from: a) skin breakdown. b) falls. c) bruises. d) wandering.

skin breakdown. Correct Explanation: The nurse uses Montgomery straps primarily to avoid the removal of long-term abdominal dressing tape and ultimate skin breakdown.

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6° F (37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and heart rate (HR) 78 bpm, but are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)? a) temperature 100.7° F (38.2° C), BP 118/68 mm Hg, HR 84 bpm, RR 20/min b) temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24/min c) temperature 97.5° F (36.4° C), BP 98/64 mm Hg, HR 98 bpm, RR 18/min d) temperature 99.5° F (37.5° C), BP 126/80 mm Hg, HR 58 bpm, RR 16/min

temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24/min Correct Explanation: This client is exhibiting three of four signs of systemic inflammatory response syndrome (SIRS): temperature greater than 100.4° F (38° C) (or less than 96.8° F [36°C]), heart rate greater than 90 bpm, respiratory rate greater than 20 breaths/min. The fourth indicator is an abnormal white blood cell count (greater than 12,000 [12 × 109/L], less than 4000 [4 × 109/L] or greater than 10% [0.1 × 109/L] bands). At least two of these variables are required to define SIRS

When assessing a dark-skinned client for cyanosis, what should the nurse examine? a) the client's retinas b) the client's oral mucous membranes c) the inner aspects of the client's wrists d) the client's nail beds

the client's oral mucous membranes Correct Explanation: In dark-skinned clients, cyanosis can best be detected by examining the conjunctiva, lips, and oral mucous membranes. Examining the retinas, nail beds, or inner aspects of the wrists is not an appropriate assessment for determining cyanosis in any client.

A daughter is concerned that her mother is in denial because when they discuss the diagnosis of breast cancer, the mother says that breast cancer is not that serious and then changes the subject. The nurse can tell the daughter that denial can be a healthy defense mechanism if it is used: a) to permit her mother to seek unconventional treatments. b) alone and not in combination with other defense mechanisms. c) when making decisions about her care. d) to allow her mother to continue in her role as a mother.

to allow her mother to continue in her role as a mother. Correct Explanation: Denial is a defense mechanism used to shut out a situation that is too frightening or threatening to tolerate. In this case, denial allows the client to vacillate between acceptance of the illness and its treatment and denial of the actual or potential seriousness of the disease. This may allow the client more psychological freedom to maintain her current roles in the family and elsewhere. Denial can be harmful if the client ignores standard medical therapies in favor of unconventional treatments. Denial is not helpful when it interferes with a client's willingness to seek treatment or make decisions about care. Using any one defense mechanism exclusively usually reflects maladaptive coping. Other defense mechanisms that may be used include regression, humor, and sublimation

A mother comes to the clinic with her 5-year-old son who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're: a) midway between the tonsillar pillar and the uvula. b) barely visible outside the tonsillar pillar. c) touching the uvula. d) touching each other.

touching the uvula. Explanation: Tonsils that touch the uvula are rated 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are rated 4+

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. a) Leave the room to allow the client privacy to collect thoughts. b) Say to the client, "The treatments are only 3 days a week. You can live with that." c) Take a seat next to the client and sit quietly to reflect on what was said. d) Say to the client, "You're feeling upset about the news you got about the transplant." e) Say to the client, "We all have days when we don't feel like going on."

• 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." Correct Explanation: 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.