Fundamentals OVERALL QUESTIONS NEED TO BE REVIEWED

A nurse is calculating the output of a client with renal failure and takes into account all modes of fluid loss. When addressing the client's insensible fluid loss, which amount would the nurse anticipate as the usual average? A. 1500 mL/day B. 100 to 200 mL/day C. 300 to 400 mL/day D. 200 mL/day

300 to 400 mL/day Explanation: The fluid lost through insensible loss is about 300 to 400 mL/day. Insensible water loss occurs when water molecules move from an area of higher concentration, such as the body, to an area of lower concentration, like the atmosphere. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. Loss of fluid through the gastrointestinal system in the form of feces is approximately 200 mL. Normal urine output for 24 hours is approximately 1500 mL if intake is normal.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of: A. phlebitis. B. rapid fluid administration. C. an infiltration. D. a systemic blood infection.

Answer: a. Phlebitis Rationale: Phlebitis is a local infection at the sit of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

After a nurse manager implements a solution to the problem of delays in obtaining supplies, the first task for the manager is to A. Plan to monitor the supply cabinets B. Make an appointment with the chief nursing officer C. Ask the staff members for other solutions D. Assess whether the desired results have occurred

Assess whether the desired results have occurred Explanation: The nurse manager must evaluate the results of his or her efforts to determine whether the desired results have occurred.

When comparing team nursing with functional nursing, what characteristic is found? A. Team nursing is very similar to functional nursing. B. Team nursing focuses on individual client care. C. Functional nursing has a stronger focus on the client. D. Functional nursing is based on total client care.

B Feedback: In team nursing, a registered nurse and other caregivers provide care to a designated group of clients for a given shift. Team nursing modifies the depersonalized approach of functional nursing and focuses on individual client care.

In which of the following conflict resolution strategies is the conflict rarely resolved? A) Collaborating B) Compromising C) Competing D) Smoothing

D Feedback: Smoothing is an effort to complement the other party and focus on agreement rather than disagreement, thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique.

Maggie Brown, RN, is the designated charge nurse on the telemetry unit. She organizes and facilitates the unit meetings, in addition to making assignments and performing staff evaluations. Maggie's power to lead is defined by which of the following terms? A. Situational B. Democratic C. Implied D. Explicit

Explicit Explanation: Maggie's official assigned role gives her explicit power by virtue of that assignment. Implied power arises when a person who has no official assigned role assumes a leadership role by virtue of the force of her/his personality and charisma. Situational and democratic are types of leadership rather than power.

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? A. Make contact between two clean surfaces. B. Handwashing before leaving the client's room. C. Remove the garments that are most contaminated. D. Make contact between two contaminated surfaces.

Handwashing before leaving the client's room. Explanation: The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath.

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? A. Hypovolemia B. Circulatory overload C. Edema D. Hypervolemia

Hypovolemia Explanation: The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

Two nurses have requested that the nurse manager allow them to plan in-service education with creative, new education techniques. Which leadership style would be best for the nurse manager to use to get the new project completed? A. Laissez-faire leadership B. Democratic leadership C. Authoritarian leadership D. Autocratic leadership

Laissez-faire leadership Explanation: Laissez-faire leadership would work best in this situation. To allow the nurse's the creative environment they will need to complete the project, it would be better to allow them autonomy to do so. Autocratic, democratic, and authoritarian leadership styles may stifle the creativity the nurses require to complete the project.

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis

Metabolic alkalosis Explanation: Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? A. Run the electrical cord of the pump under the carpet. B. Tape the electrical cord of the pump to the floor. C. Obtain a three-prong grounded plug adapter. D. Use an extension cord to provide freedom of movement.

Obtain a three-prong grounded plug adapter. Explanation: The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety.

Which action is the best example of a nurse donning/removing protective equipment properly? A. Removing gown after leaving client's room B. Removing respirator after leaving client's room C. Donning respirator inside of client's room D. Donning gown after entering client's room

Removing respirator after leaving client's room Explanation: The best example of proper utilization of protective equipment is the removal of a respirator after leaving the client's room, as doing so prevents contact with airborne microorganisms. Gowns should be removed before leaving the client's room. Gowns and respirators should be donned prior to entering the client's room.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? A. Assess for visible rash. B. Call for assistance. C. Assess oxygen levels. D. Stop the transfusion.

Stop the transfusion. Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.

When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow? A. Use small veins before larger veins. B. Use veins of the lower extremities. C. Use distal veins before proximal veins. D. Use the brachial plexus vein.

Use distal veins before proximal veins. Explanation: Use larger veins and the distal portion of the vein, leaving the more proximal sites for later venipunctures.

A nurse is documenting care in a source oriented record. what action by the nurse is most appropriate?

WRITE A NARRATIVE NOTE IN THE DESIGNATED NURSING SECTION source oriented record have separate sections for each discipline to document their own information.

What is the micturition reflex?

You Selected: The reabsorption of the substances the body wants to retain. Correct response: The act of bladder contraction and perceived need to void. Explanation: Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?

You Selected: hemolytic reaction Correct response: febrile reaction Explanation: Febrile reaction to blood components can occur because of the recipient's hypersensitivity to the donor's white blood cells. In this reaction, the client develops a fever and chills and may complain of a headache and malaise.

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? A. Colloid B. Isotonic C. Hypertonic D. Hypotonic

b) Isotonic fluids Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

During a blood transfusion, a client displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect? A. hemolytic transfusion reaction: incompatibility of blood product B. allergic reaction: allergy to transfused blood : C. febrile reaction: fever develops during infusion D. bacterial reaction: bacteria present in the blood

hemolytic transfusion reaction: incompatibility of blood product Explanation: The symptoms of facial flushing, fever, chills, headache, low back pain, and shock occur when a blood product is incompatible and the client is experiencing a hemolytic transfusion reaction. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever, hypertension, dry, flushed skin, and abdominal pain occur.

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? A. increased respiratory rate B. renal retention of H ions C. increased excretion of bicarbonate ions by the kidneys D. hypoventilation

increased respiratory rate Explanation: Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35 to 7.45. Retention of hydrogen ions, increased excretion of bicarbonate ions, and hypoventilation are all processes that contribute to decreased pH and an exacerbation of acidosis.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? A. Most home fires are caused by children playing with matches. B. Most fatal home fires occur while people are cooking. C. About 10% of home fire deaths occur in a home without a smoke detector. D. Most people who die in house fires die of smoke inhalation, rather than burns.

most people who die in house fires die of smoke inhalation, rather than burns. Explanation: Most people who die in house fires die of smoke inhalation, rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes Explanation: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.

The ANA, which is committed to monitoring the regulation, education, and use of NAPs, recommends adherence to which one of the following principles? A) It is the nursing profession that determines the scope of nursing practice. B) It is the RN who defines and supervises the education, training, and use of any unlicensed assistant roles. C) It is the assigned NAP who is responsible and accountable for his or her nursing practice. D) It is the purpose of the RN to work in a supportive role to the assistive personnel.

A Feedback: It is the nursing profession that determines the scope of nursing practice, and defines and supervises the education, training, and use of any unlicensed assistant roles involved in providing direct nursing care. It is the registered nurse who is responsible and accountable for nursing practice, and who supervises any assistant involved in providing direct client care. It is the purpose of assistive personnel to work in a supportive role to the registered nurse, carrying out tasks that enable the professional nurse to concentrate on caring for the client.

What type of leadership can a graduate nurse working in a magnet hospital expect? A. Democratic B. Autocratic C. Situational D. Quantum

A. Working in a magnet hospital can maximize the potential of new graduates who prefer democratic leadership.

A nurse is in charge of a large group of employees on a busy surgical floor. Today's care must be completed early due to a special event involving most of the employees. Which management style would work best in this situation? A. Authoritarian B. Coercive C. Democratic D. Laissez-faire

Authoritarian Explanation: With authoritarian, or autocratic, leadership, the activities of the group are primarily directive, with activities determined by the leader and dictated to the followers, with no input from the followers on decisions. Coercive management forces actions upon staff. Democratic leadership is appropriate when the task, or decision at hand, is not one that requires urgent action, when subordinates can be expected to make meaningful contributions, and when their input can be taken into account. Laissez-faire management provides little or no direction; coworkers develop their own goals, make their own decisions, and take responsibility for their own management.

During a staff meeting, the nurse is discussing new quantum leadership. The nurse explains that in this type of leadership change is viewed as which of the following? A. Constant and predictable B. Dynamic and constantly unfolding C. Evolving very slowly D. An entity needing planning

B Feedback: We are in a difficult transition period between the old and the new age. In the old age, change was viewed as an entity to be planned, carefully managed, and accepted. In the new quantum age, change is conceived as dynamic, ever-present, and continually unfolding.

The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the the education provided was effective? Select all that apply. A. "I may transmit the virus to my child during pregnancy and childbirth." B. "If someone is exposed to my blood, I may transmit the virus to him or her." C. "If someone uses the bathroom after I have been on the toilet, he or she can catch the virus." D. "If I sweat at the gym and someone touches me, he or she can contract the virus." E. "I may transmit the virus if I share needles with another person."

B. "If someone is exposed to my blood, I may transmit the virus to him or her." A. "I may transmit the virus to my child during pregnancy and childbirth." E. "I may transmit the virus if I share needles with another person." Explanation: The client has demonstrated that an understanding of the transmission of the virus may occur through exposure to blood, during pregnancy and childbirth, and through sharing needles. Transmission of the virus does not occur through sweat or by exposure on a toilet seat. The virus is fragile and does not live on inanimate objects.

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDA) in bedside care. This study is tangible application of what? A. telemedicne B. nursing informatics C. electronic medical records D. computerized documentation

B. nursing informatics 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 hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note, in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? A. Variance charting B. Problem, Intervention, Evaluation (PIE) charting C. Charting by exception (CBE) D. FOCUS charting

C. charting by exception

A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "how do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which of the following interviewing techniques? A. reflective question B. validating question C. open ended question D. closed question

C. open ended question nurses question allows for wide range of responses and encourages free verbalization, characteristics of a useful open ended question.

A nurse is interviewing a client for the establishment of long term care insurance. During the interview, the nurse ask questions regarding the client's past medical history. The nurse is the? A. receiver B. target C. sender D. decoder

C. sender sender is a person with a purpose for the communication

Two new graduate nurses are requesting the same preceptor for unit orientation. Both new graduates have been very vocal about being unhappy if they do not receive their choice of preceptor. The nurse manager sets up a meeting with the new graduate nurses in order to come to a resolution regarding the preceptor. Which conflict resolution style is the nurse manager using? A. Collaborating B. Compromising C. Avoiding D. Accommodating

Collaborating Explanation: Collaborating involves working with all parties to resolve the assignment issue. Compromising involves discussing with the new graduate nurses independently to develop a mutually agreeable solution. Accommodating involves the nurse manager independently placing one new graduate nurse with the preceptor and disregarding the other new nurse graduate's upset feelings. Avoiding involves the nurse manager ignoring the problem altogether.

A nurse is providing care to a client diagnosed with impetigo. The nurse would institute which type of infection control? A. Airborne precautions B. Protective isolation C. Droplet precautions D. Contact precautions

Contact precautions Explanation: Contact precautions are used with organisms that can be transmitted by hand- or skin-to-skin contact (e.g., during client care activities or when touching the client's environmental surfaces or care items) such as with a client with impetigo. Airborne precautions are used to protect against microorganisms transmitted by small-particle droplets that can remain suspended and become widely dispersed by air currents, such as tuberculosis or measles. Droplet precautions are used for microorganisms transmitted by larger-particle droplets which disperse into air currents, such as H. influenzae or M. pneumoniae. Protective isolation is used to prevent infection for people whose body defenses are known to be compromised, such as those who are neutropenic secondary to chemotherapy.

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results? A. Flow sheets B. Medical records C. Progress notes D. Graphic sheets

D. graphic sheet

A nurse manager of a hospital unit is working within a decentralized management structure. Which nursing action best exemplifies this type of system? A. Nurse managers are not accountable for client, staffing, supplies, or budgets. B. Decisions are made by those who are most knowledgeable about the issue. C. Nurses are not intimately involved in decisions involving client care. D. Senior managers make all the decisions.

Decisions are made by those who are most knowledgeable about the issue. Explanation: The best example of a nurse manager of a hospital unit working within a decentralized management structure would be that decisions are made by those who are most knowledgeable about the issue. Nurses would be greatly involved in decisions involving client care. Senior managers would not make all the decisions within a decentralized management structure. Nurse managers could be accountable for client, staffing, supplies, and/or budgets.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? A. Maceration B. Evisceration C. Desiccation D. Necrosis

Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

A nurse is successful in promoting change on his nursing division. This nurse would be considered a A. Guide B. Manager C. Leader D. Specialist

Leader Explanation: Leadership focuses on people and inspires them to perform or to change.

A nurse manager is educating his staff in new forms of charting. Within the education session, the manager sets a goal for complete use of the charting. Through goal setting, the manager is acting as a(an) A. Educator B. Clinic specialist C. Guide D. Leader

Leader Explanation: Leadership is the ability to influence others to strive for a vision or goal or to change.

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client? A. Enzymatic debridement B. Autolytic debridement C. Biosurgical debridement D. Mechanical debridement

Mechanical debridement Explanation: Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed.

A nurse arranges all the resources available to teach a teenage girl how to manage her asthma. Which role is this nurse performing? A. planning B. controlling C. directing D. organizing

Organizing role Explanation: The role of management is to plan, organize, direct, and control available human, material, and financial resources to deliver quality care to clients and families. Organizing would include acquiring, managing, and mobilizing resources to meet both clinical and financial objectives. Planning would include identifying problems and developing goals, objectives, and related strategies to meet the demands identified. Directing would include leading others in achieving goals within the constraints of the setting. Controlling would include implementing mechanisms for ongoing evaluation in the setting.

Health care facility plan to evaluate and revise the plan of care for a client based on the client's health care records. Physician, dietitian, and nurse involved in client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client's detail? A. Narrative charting B. FOCUS charting C. SOAP charting D. PIE charting

SOAP CHARTING SOAP charting, everyone involved in care makes entries in the same location in the chart NARRATIVE charting is time consuming to write and read, as it is involved sorting through the lengthy notations FOCUS charting follows DAR(data, action,response) model PIE charting is a method of recording the client's progress under the heading of problem, intervention, and evaluation.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document? A. Purulent B. Serous C. Serosanguineous D. Sanguineous

Serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors such as green or yellow; this drainage indicates infection.

The case manager works in a facility that supports a participative leadership style. Which of the following should the nurse recognize as an example of democratic leadership style? A. The dietitian completing a nutritional assessment for a registered nurse (RN) B. The interdisciplinary health care team collectively developing plans of care for clients C. The unlicensed assistive personnel (UAP) taking vital signs for several nurses D. The nurse implementing the physician's written orders for client care

The interdisciplinary health care team collectively developing plans of care for clients Explanation: Democratic leader or participative leadership style is characterized by a sense of equality among the leader and other participants. The interdisciplinary health care team collectively developing plans of care for clients is the only option that shows shared responsibility to achieve the same client outcome.

Which fluid should be administered slowly to prevent circulatory overload?

You Selected: 0.45% NaCl Correct response: 5% NaCl Explanation: When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% NaCl and 5% NaCl.

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? A. Use respiratory protection when entering the room of client with known or suspected diphtheria. B. Wear PPE when entering the room for all interactions that may involve contact with the client. C. Place client in private room that has monitored negative air pressure. D. Use a private room with the door closed.

Wear PPE when entering the room for all interactions that may involve contact with the client. Explanation: The nurse should wear PPE upon entry into the room for all interactions that may involve contact with the client. The nurse should use a private room, if available, and the door may remain open. Placing a client in a private room that has monitored negative air pressure is appropriate for airborne infections. The nurse should use respiratory protection when entering the room of the client with known or suspected tuberculosis (airborne infection).

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? A. transparent films B. hydrocolloid dressings C. alginates D. hydrogels

hydrocolloid dressings Explanation: Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small, partial-thickness wounds with minimal drainage.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: A. to provide drainage for bile. B. to provide a sinus tract for drainage. C. to divert drainage to the peritoneal cavity. D. to decrease dead space by decreasing drainage.

to provide drainage for bile. Explanation: A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

What type of leader shares decisions and activities with group participants? A. Democratic B. Autocratic C. Laissez-faire D. Situational

A Feedback: Democratic leadership, also called participative leadership, is characterized by equality among the leader and other participants. Decisions and activities are shared.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains? A. A Penrose drain is a closed drainage system that is connected to an electronic suction device. B. A Penrose drain promotes drainage passively into a dressing. C. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. D. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

A Penrose drain promotes drainage passively into a dressing. Explanation: A Penrose drain is an open drainage system that promotes drainage of fluid passively into a dressing. Additional drains include the Jackson-Pratt drain that has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

The nurse and physical therapist discuss the therapy schedule and goals for a patient on a rehab unit. What type of communication is occurring between the nurse and the therapist? A. interpersonal B. small group C. intrapersonal D. organizational

A. interpersonal INTERPERSONAL- occur between two or more people with the goal to exchang messages. INTRAPERSONAL- or self talk, is communication that happens within the individual. SMALL GROUP- communication occurs when nurse interact with two or more individuals organizational- communication occurs when individuals and groups within an organization communicates to achieve established goals

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? A. Position the client on the left side. B. Elevate the client's head. C. Apply antiseptic and a dressing. D. Apply a warm compress.

Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

A grade school nurse is addressing parents at a PTA meeting regarding car safety. Which of the following is a recommended safety guideline for this age group? A. All school-age children need to be secured in safety seats. B. Booster seats should be used for children until they are 4 feet 9 inches tall or at least 8 years of age. C. Children under 8 years old should ride in the back seat. D. All school-age children need to be secured in lap seat belts.

B Feedback: All school-age children need to be secured in safety seats, belt-positioning booster seats, or shoulder lap belts for their size. The National Highway Traffic Safety Administration recommends booster seats for children until they are 4 feet 9 inches tall or at least 8 years of age, and all children 12 and under should ride in the back seat to eliminate the risk of injury from airbag deployment (National Highway Traffic Safety Administration [NHTSA], 2008).

The nurse is caring for a client who had a sudden episode of vomiting, which produced 900 mL of frank blood. The nurse directed and delegated to colleagues in order to notify the physician. She started intravenous fluids, and provided physical and emotional support for the client. Different situations call for different leadership styles. Which of the following leadership styles did the nurse display in this situation? A. Democratic B. Laissez-faire C. Autocratic D. Transformational

C Feedback: Autocratic leadership involves the leader assuming complete control. Democratic leadership displays a sense of equality among the leader and other participants. With laissez-faire leadership, the leader relinquishes power to the group. Transformational leaders create intellectually stimulating practice environments and challenge themselves and others to grow personally and professionally, and to learn.

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance? A. Hypermagnesemia B. Hypokalemia C. Hyperphosphatemia D. Hyponatremia

Correct response: Hyperphosphatemia Explanation: Calcium and phosphorus have a reciprocal relationship—if the calcium level is low, the phosphorus level would be high. A magnesium deficiency, not excess, may be accompanied by hypocalcemia. Sodium and potassium deficiencies are not typically associated with low calcium levels.

In Lewin's classic theory of change, what happens during unfreezing? A) Planning is conducted. B) Change is initiated. C) Change becomes operational. D) The need for change is recognized.

D Feedback: In Lewin's change theory, during unfreezing the need for change is recognized. Unfreezing does not include planning, initiating, or operationalizing change.

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client? A. Traditional water seal B. Wet suction C. Dry suction water seal D. Dry suction/one-way valve system

D Feedback: The dry suction or one-way valve system works even if knocked over, making it ideal for clients who are ambulatory.

The nurse has recently been promoted to nurse manager on a pediatric unit and has decided to accept input from staff regarding changes they would like to see on the unit. Which type of leadership style is the nurse embodying? A. Quantum B. Laissez-faire C. Autocratic D. Democratic

Democratic Explanation: Democratic leadership style involves sharing the decision making process and activities with others who have an interest. Autocratic leadership style involves assuming control over the decisions and activities of the group. Laissez-faire leadership style involves the leader relinquishing power or control to the group. Quantum leadership style involves seeing an organization and members as interconnected and collaborative. This style involves change as continually unfolding, and frequently incorporates technology.

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound? A. Saline-moistened dressing B Dressing secured with Montgomery straps C. Hydrocolloid dressing D. Foam dressing

Hydrocolloid dressings are used for wounds that are shallow to moderate depth with minimal drainage. Saline-moistened dressing is often used with chronic wounds and pressure wounds. Montgomery straps are recommended to secure dressings on wounds that require frequent dressing changes, such as wounds with increased drainage. Foam dressings are recommended for chronic wounds.

The designated charge nurse on the telemetry unit organizes and facilitates the unit meetings; however, during most of the meetings, another registered nurse runs the show and influences staff decisions just by her charisma and personality. Her power to lead is defined by which of the following terms? A. Implied B. Democratic C. Situational D. Explicit

Implied Explanation: Implied power arises when a person who has no official assigned role assumes a leadership role by virtue of the force of his or her personality and charisma. The designated charge nurse's official assigned role gives her explicit power by virtue of that assignment. Situational and democratic are types of leadership rather than power.

The unit manager on a medical unit is trying to encourage the nursing staff to use a new protocol for documentation. To help with this, the nurse manager recruits one of the staff nurses who serves as a role model for many of the staff. Which type of power does the staff nurse exhibit? A. Legitimate B. Explicit C. Implied D. Coercive

Implied Explanation: The staff nurse, as a role model for the rest of the staff and, therefore, influential with making change, would have implied power. Explicit or legitimate power is that power that is directly given, such as with the unit manager role; coercive power is a negative type of power that results from using threats or negative punishment to force someone to do what they do not want to do.

Nurse is maintaining a problem oriented medical record fora client. which component of the record describes the client's responses to what has been done and revisions to the initial plan?

PROGRESS NOTE In problem oriented medical record, progress note describe client's response to what has been done and revision initial plan

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? A. Remove the IV. B. Slow the rate of IV fluids. C. Apply a warm compress. D. Elevate the arm.

Remove the IV. Explanation: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

A nurse manager must provide care to the units clients and employees under the constraints of the resources. This involves maintaining the financial constraints of the division. What term best describes this scenario? A. Allocation B. Resource management C. Financial management D. Management

Resource management Explanation: In modern health care organizations, managers usually are responsible for accomplishing the work of the unit within the constraints of available resources. This process is called resource management. Allocation is the assignment of available resources to various uses. Management is the process of dealing with or controlling things or people. Financial management is the process of dealing with or controlling money.

The nurse is advising a client about health problems related to being overweight. The client acknowledges the need to lose weight. The nurse provides education on how to count calories in food and the importance of daily exercise. The client states she will begin to count caloric intake beginning with the next meal. The client also states intentions to begin an exercise program with friends. Which statement illustrates Lewin's stage of unfreezing? A. The client also states intentions to begin an exercise program with friends. B. The nurse provides education on how to count calories in food and the importance of daily exercise. C. The client acknowledges the need to lose weight. D. The client states she will begin to count caloric intake with the next meal.

The client acknowledges the need to lose weight. Explanation: Unfreezing recognizes the need for change. The client's acknowledgment of the need to lose weight is the only example provided of unfreezing.

The nursing student who is learning skills during campus lab identifies which statement about bedpans to be true?

You Selected: A fracture bedpan should be used only for clients who have fractures of the femur or lower spine. Correct response: The rounded shelf of a regular bedpan should be placed under the client's buttocks. Explanation: The only true statement is that the rounded shelf of the regular bedpan should be placed under the client's buttocks. Very thin and older adult clients may prefer the fracture bedpan. Both types of bedpans can be used for either urination or defecation. A fracture bedpan can be used for any client.

The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:

You Selected: decreased skin area. Correct response: increase in fat cells. Explanation: The decreasing percentage of body fluid in older adults is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults. Older adults do not have an increase muscle mass, smaller stomach capacity, or decrease skin area.

The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? A. contact B. droplet C. none D. airborne

droplet Explanation: Streptococcal pneumonia is transmitted through droplets; therefore, droplet contact precautions are appropriate. The other options are inappropriate.

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction?

You Selected: "The heart circulates water and nutrients through the body." Correct response: "The kidneys store and release antidiuretic hormone to increase water retention." Explanation: The pituitary glands store and release antidiuretic hormone rather than the kidneys. The other statements are correct regarding fluid and electrolyte balance.

Question 13 See full question 45s Two new graduate nurses are requesting the same preceptor for unit orientation. Both new graduates have been very vocal about being unhappy if they do not receive their choice of preceptor. The nurse manager sets up a meeting with the new graduate nurses in order to come to a resolution regarding the preceptor. Which conflict resolution style is the nurse manager using?

You Selected: Accommodating Correct response: Collaborating Explanation: Collaborating involves working with all parties to resolve the assignment issue. Compromising involves discussing with the new graduate nurses independently to develop a mutually agreeable solution. Accommodating involves the nurse manager independently placing one new graduate nurse with the preceptor and disregarding the other new nurse graduate's upset feelings. Avoiding involves the nurse manager ignoring the problem altogether.

A nurse is preparing a presentation for a group of older adults at a local senior center about the importance of fluid intake. As part of the presentation, the nurse plans to discuss how the intake and output of fluids is typically balanced each day. When describing the normal daily output of fluids, which component would the nurse identify as accounting for the smallest amount of fluid output?

You Selected: Exhaled air Correct response: Perspiration Explanation: Normal urine output for 24 hours is approximately 1,500 mL if intake is normal. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. In addition to perspiration, insensible fluid loss through the skin amounts to about 300 to 400 mL per day. Loss of fluid through the gastrointestinal system in the form of feces is usually minimal, approximately 200 mL per day. Loss of water through respiration is approximately 300 mL per day.

A nurse manager is implementing the function of directing in his or her role on the unit. Which action by the nurse manager demonstrates this role?

You Selected: Identifying a goal for the nurse-client ratio on the clinical unit Correct response: Helping manage unit flow with client care if there is a staff call-out Explanation: The four managerial functions are planning, organizing, directing, and controlling. Directing is leading others to achieve the goals of the unit; in this case, helping on the unit with client care, if there is inadequate staffing. Planning involves identifying a problem, which, in this case, involves having an adequate amount of staff for the clinical unit; this function also involves having goals and strategies to achieve an adequate nurse-client ratio. The controlling phase includes implementing mechanisms for ongoing evaluation; the nurse manager will do this when checking the budget weekly to be sure the resources are adequate. The organizing phase would involve hiring the staff.

Question 4 See full question 29s The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?

You Selected: Paralytic ileus Correct response: Diarrhea Explanation: The client with hyperkalemia would experience diarrhea. Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia.

Conflict has emerged on a nursing unit due to the perception by new graduates that some of the more experienced nurses are manipulating the client assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict? A. Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. B. Reassure the new graduates that the more experienced nurses are acting in the interests of both staff and clients. C. Arrange for the newer nurses to organize the client assignment for a trial period. D. Gather evidence over the next several weeks in order to determine if the practice is indeed happening.

Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. Explanation: Open, explicit, and participatory conflict resolution that is based on collaboration is an effective strategy for the management of conflict. Gathering evidence does not directly address the conflict that currently exists and reassurance may be unwarranted and false. Allowing the new graduates to create the client assignment may perpetuate selfish practices and does not resolve animosity between the two camps.

Which of the following nurse leaders most clearly exemplifies transformational leadership?

Correct response: A leader who is dynamic, inspiring, and promotes change by the power of her convictions Explanation: Transformational leaders can create revolutionary change. They are often described as charismatic, and they are unique in their ability to inspire and motivate others. A careful examination of contextual factors is associated with situational leadership. Delegation to group members and an emphasis on equality are typical of laissez-faire and democratic leadership.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: A. preventing excretion of acids into the urine. B. increasing the excretion of HCO into the urine. C. increasing ventilation through the lungs. D. increasing the excretion of H ion into the urine.

Correct response: increasing ventilation through the lungs. Explanation: The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. To compensate for respiratory alkalosis, the kidneys increase the excretion of HCO to the urine. Kidneys compensate for respiratory acidosis by increasing the excretion of H ion into the urine. The kidneys respond to metabolic alkalosis by retaining acid and excreting HCO.

A registered nurse (RN) serves as the chair of the Nursing Practice Committee for the hospital. The meetings do not have a planned agenda; members of the committee who are interested in a particular topic feel free to suggest it and then to lead the subsequent discussion. This chairman's leadership style could be termed what? A. Laissez-faire B. Democratic C. Autocratic D. Decentralization

Laissez-faire Explanation: Little or no direction is provided in laissez-faire management: coworkers develop their own goals, make their own decisions, and take responsibility for their own management. Democratic leadership, also known as participative leadership or shared leadership, is a type of leadership style in which members of the group take a more participative role in the decision-making process. Autocratic leadership, also known as authoritarian leadership, is a leadership style characterized by individual control over all decisions and little input from group members. Decentralized decision-making is any process where the decision-making authority is distributed throughout a larger group.

The nurse manager notices a trend in nurses routinely arriving to work late. How can the nurse use the transactional leadership style to get nurses to arrive to work on time? A. Monitor time clock reports on a monthly basis and enter all nurses who have not been tardy into a raffle for a paid day vacation. B. Generate a report of nurses who routinely arrive to work late and set an example by firing the nurse who has been tardy the most. C. Emphasize the importance of arriving to work on time during a monthly unit meeting. D. Allow the nursing staff to develop a plan to decrease tardiness within the unit.

Monitor time clock reports on a monthly basis and enter all nurses who have not been tardy into a raffle for a paid day vacation. Explanation: Transactional leadership style involves creating a reward system to get the desired outcome. Entering the nurses who have not been tardy is the only option that provides a reward. Allowing the nursing staff to assist in correcting the problem is an example of democratic leadership style. Emphasizing the importance of arriving to work on time is an example of autocratic leadership. Firing is an example of coercive power.

A nurse arranges all the resources available to teach a teenage girl how to manage her asthma. Which role is this nurse performing?

You Selected: Planning role Correct response: Organizing role Explanation: The role of management is to plan, organize, direct, and control available human, material, and financial resources to deliver quality care to clients and families. Organizing would include acquiring, managing, and mobilizing resources to meet both clinical and financial objectives. Planning would include identifying problems and developing goals, objectives, and related strategies to meet the demands identified. Directing would include leading others in achieving goals within the constraints of the setting. Controlling would include implementing mechanisms for ongoing evaluation in the setting. Reference:

While assessing a client, the nurse notices that the client seems to be distracted from the questions being asked. The nurse attempts to identify factors that may be affecting the communication. What would the nurse identify as an internal influencing factor?

You Selected: Privacy Correct response: Experience Explanation: The client's past experience, an internal influence, may affect the nurse-client communication. Noise, privacy, and ambience are external factors that affect the communication between a nurse and client. Other internal influences that may affect the nurse-client communication are cultural background and beliefs.

Two new graduate nurses are requesting the same preceptor for unit orientation. Both new graduates have been very vocal about being unhappy if they do not receive their choice of preceptors. Which illustrates the nurses using an accommodating approach to conflict resolution?

You Selected: The nurses discuss the situation with the preceptor to come to an agreement mutually beneficial for both parties. Correct response: One nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend. Explanation: Accommodation involves one party deciding to let the other party win in exchange for something else of value. The nurses making an arrangement illustrates accommodation. In compromise both parties are willing to relinquish something of equal value. The nurses' decision to share the preceptor, one at the beginning of the orientation and the other one at the end of the orientation, demonstrates compromise. Each nurse ignoring the other's request illustrates avoidance. Allowing the preceptor to decide which nurse she will precept encourages competition. Competition involves a win-lose approach to conflict.

A client with renal disease requires IV fluids. It is important for the nurse to:

You Selected: check the intravenous rate once a shift. Correct response: place the fluids on an electronic device. Explanation: An IV electronic infusion device usefully and accurately regulates the infusion rate, especially if fluid administration must be watched very carefully, such as when infusing fluid to a renal client or when administering certain medications.

The nurse is caring for a 7-year-old client with varicella. Which precautions will the nurse initiate?

You Selected: contact Correct response: airborne Explanation: Varicella is transmitted via airborne mechanisms; therefore, airborne precautions are appropriate.

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

You Selected: renal retention of H ions Correct response: increased respiratory rate Explanation: Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35 to 7.45. Retention of hydrogen ions, increased excretion of bicarbonate ions, and hypoventilation are all processes that contribute to decreased pH and an exacerbation of acidosis.

Which type of wound drainage should alert the nurse to the possibility of infection? A. copious wound drainage that is blood-tinged B. drainage that appears to be mostly fresh blood C. large amounts of drainage that is clear and watery D. foul-smelling drainage that is grayish in color

foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection.

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? A. "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." B. "Drug resistance can develop when the wrong antibiotic is used for pneumonia." C. "This antibiotic is the best choice since the causative organism is not known." D. "Pneumonia is usually caused by multiple organisms."

"This antibiotic is the best choice since the causative organism is not known." Explanation: Broad spectrum antibiotics are appropriate when the client is symptomatic and the causative bacteria is not yet known. These agents produce the best chance of effectiveness. The side effects of all antibiotics are similar. The antibiotic can cause resistance when used excessively in the absence of infection. Pneumonia may or may not be caused by multiple organisms; however, this isn't the best answer regarding the medication.

The nurse has just graduated with a Bachelor of Science in Nursing and is eager to find a mentor at this early stage in her career. Which of the following individuals is most likely to be an appropriate mentor for the nurse? A. An experienced nurse who was a preceptor in a previous clinical placement B. The nurse educator on the hospital unit where the novice nurse has been hired C. A colleague who graduated with honors at the same time as the novice nurse. D. The unit manager who the novice nurse.

A Feedback: A person who demonstrates positive qualities and who possesses more experience is often a good choice to be a nurse's mentor. A person in formal authority or oversight, such as the unit educator or manager, is a less ideal choice, and a peer is not normally an ideal choice of mentor.

A nurse strives to establish trusting interpersonal relationships with clients, peers, subordinates, and superiors to facilitate goal achievement and personal growth of all participants. Which type of skills is this nurse demonstrating? A. Communication skills B. Problem-solving skills C. Management skills D. Self-evaluation skills

A Feedback: Communication skills involve the ability to establish trusting interpersonal relationships with clients, peers, subordinates, and superiors to maximize goal achievement and enhance the personal growth. Problem-solving skills refer to the ability to analyze all sides of a problem, to suspend judgment, to explore multiple options, and to work toward a creative solution. Management skills pertain to the ability to direct others toward goal achievement. Self-evaluation skills involve the ability to assess honestly one's effectiveness, to accept both praise and criticism, and to direct personal professional growth and development.

A student nurse has just graduated with a baccalaureate degree in nursing. What type of nursing leadership will this nurse be expected to provide? A. Nursing care of the individual client B. Demonstration of selected critical skills C. Ability to be a follower rather than a leader D. Nursing care of groups of clients

A Feedback: New graduates have leadership responsibilities when they begin nursing. Nursing leadership begins with nursing care of the individual client.

A nurse is described as a "quantum leader." Which action characterizes this type of leadership? A. A nurse conducts a blind survey to evaluate her leadership skills. B. A nurse relinquishes power to a group deciding hospital policy. C. A nurse makes policy decisions for coworkers without consulting them. D. A nurse sticks to the "tried and true" methods when implementing client care.

A Feedback: Quantum leaders must have excellent communication skills, encourage personal critiques, and challenge current ways of thinking and doing. A nurse who relinquishes power to a group to make decisions is using laissez-faire leadership. A nurse making decisions for coworkers without considering their feelings is an autocratic leader.

Nurses with varying levels of experience possess leadership skills. A graduate nurse walks out of the nurse manager's office after a meeting. The graduate nurse reflects on the positive and negative feedback that she received from the manager regarding her three months working on the unit. What nursing leadership skill is best illustrated by the graduate nurse in this scenario? A. Self-evaluation skills B. Communication skills C. Problem-solving skills D. Management skills

A Feedback: Self-evaluation skills incorporate the ability to assess honestly one's effectiveness, to accept both praise and criticism, and to direct personal professional growth. Communication skills demonstrate the ability to establish trusting interpersonal relationships with clients, peers, subordinates, and superiors to maximize goal achievement. Problem-solving skills include the ability to analyze all sides of a problem, to suspend judgment, to explore multiple options, and to work toward a creative solution. Management skills are the ability to direct others toward goal achievement.

In light of the failure of alternatives, a nurse has been forced to physically restrain an agitated client. Which of the following actions should the nurse perform when applying and maintaining the restraints? A. Tie the client's hand restraint to the bed frame rather than the side rail. B. Obtain a physician's order for the restraints within 24 hours. C. Ensure the client is under continuous surveillance while restrained. D. Choose a restraint device that best minimizes the client's mobility.

A Feedback: Restraints should be tied to the frame of the bed rather than to the side rails. A physician's order is needed for restraints, except in emergencies when an order must be obtained within one hour of application. Frequent assessment of the client is needed, but continuous surveillance is not necessarily required. The least restrictive type of device that allows the greatest mobility, while still ensuring safety, is chosen.

A nurse manager has directed a registered nurse who is out of school for one year to become a member of the institution's policy and procedure committee. A goal in the nurse manager's delegation is to assist the nurse to what? A. Be involved in the hospital B. Be confident in employment C. Grow in her profession D. Understand the hospital setting

C Feedback: Delegation of activities to staff members will assist them to grow and become more committed to their organization.

Which of the following is a characteristic of mentorship? It is a paid position to orient new nurses to the workplace. It involves membership in a professional organization. It is a link to a protégé with common interests. It is not encouraged in health care settings

C Feedback: Mentorship is a relationship in which an experienced individual (the mentor) advises and assists a less experienced individual (protégé). This is an effective way of easing a new nurse into leadership responsibilities. Mentors link with protégés by common interest and provide support, information, and network links. The relationship does not include financial reward. An alternative model is preceptorship. The preceptor (experienced nurse) is selected (and generally paid) to introduce an employee to new responsibilities through education and guidance.

20. Which of the following statements accurately describes the use of power by change agents? A) They know that power comes from one source— management. B) When introducing change they do not enlist the support of key power players. C) They are often accomplished professional women. D They do not recognize their own strengths and weaknesses.

C Feedback: Power,the ability to influence others to achieve a desired effect, has many sources. When introducing change, it is helpful to recognize and enlist the support of key power players who can then encourage others to become involved. Women are accomplished professionals and occupy powerful leadership positions in corporations, health care organizations, and political arenas. Nursing leaders recognize the strengths and limitations of their own power and encourage others to develop and use power constructively.

The nurse manager for the psychiatric unit sees that there are major conflicts between the day and night shift staff. The nurse manager suggests that each shift put aside their differences for a time and determine a common major goal. Which of the following conflict resolution styles does the nurse manager display? A. Smoothing B. Collaborating C. Competing D. Avoiding

Collaborating Explanation: With "collaborating" there is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. With "avoiding" there is awareness of the conflict situation, but the parties involved decide to either ignore the conflict or avoid/postpone its resolution. "Competing" is an approach that results in a win for one party at the expense of the other. "Smoothing" is an effort to complement the other party and focus on agreement rather than disagreement, thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique.

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? (Select all that apply.)

Correct response: A B AB O Explanation: Persons with type AB blood are often called universal recipients, a fact that is rooted in their lack of agglutinins for either A or B antigens.

A client has the following arterial blood gas results: pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L (19 mmol/L) PaO2: 95 mm Hg Which imbalance would the nurse suspect? Respiratory acidosis Metabolic acidosis Respiratory alkalosis Metabolic alkalosis

Correct response: Metabolic acidosis Explanation: The results reveal metabolic acidosis, which is characterized by a pH lower than 7.35 and a plasma HCO3 concentration lower than 22 mEq/L (22 mmol/L). Respiratory acidosis is indicated by a low pH accompanied by an increased arterial concentration of carbon dioxide, which often is clinically defined as a PaCO2 of greater than 45 mm Hg. Respiratory alkalosis is present when a high pH is accompanied by a blood carbon dioxide concentration lower than 35 mm Hg. Metabolic alkalosis is characterized by a pH higher than 7.45 and a plasma HCO3 concentration above 26 mEq/L (26 mmol/L).

A nurse working on leadership skills should keep in mind which of the following accurate statements regarding leaders? A. People are born leaders. B. Leadership should be approached quickly. C. Leaders develop leadership skills in undefined situations. D. All nurse leaders began as inexperienced nurses.

D Feedback: Leadership should be approached like any other new role or skill: slowly and carefully. Nursing students and beginning nurses should be prepared with all of the necessary tools or skills before attempting the new role. Initially, nurses develop leadership skills in well-defined clinical situations. With each experience, growth occurs and leadership is strengthened. All nurse managers, nurse administrators, and nursing leaders also began as inexperienced nurses.

A nurse leader is described as charismatic, motivational, and passionate. Communications are open and honest, and the nurse is willing to take risks. What type of leadership is the nurse practicing? A. Democratic B. Autocratic C. Quantum D. Transformational

D Feedback: Transformational leaders are often described as charismatic, challenging, and passionate about their vision. They communicate openly and honestly, show concern for others, and are willing to take risks.

A nurse manager is implementing the function of directing in his or her role on the unit. Which action by the nurse manager demonstrates this role? A. Utilizing a weekly system for keeping workforce budget balanced B. Helping manage unit flow with client care if there is a staff call-out C. Identifying a goal for the nurse-client ratio on the clinical unit D. Hiring an adequate amount of nurses to staff the unit on all shifts

Helping manage unit flow with client care if there is a staff call-out Explanation: The four managerial functions are planning, organizing, directing, and controlling. Directing is leading others to achieve the goals of the unit; in this case, helping on the unit with client care, if there is inadequate staffing. Planning involves identifying a problem, which, in this case, involves having an adequate amount of staff for the clinical unit; this function also involves having goals and strategies to achieve an adequate nurse-client ratio. The controlling phase includes implementing mechanisms for ongoing evaluation; the nurse manager will do this when checking the budget weekly to be sure the resources are adequate. The organizing phase would involve hiring the staff.

Two new graduate nurses are requesting the same preceptor for unit orientation. Both new graduates have been very vocal about being unhappy if they do not receive their choice of preceptors. Which illustrates the nurses using an accommodating approach to conflict resolution? A. The nurses will allow the preceptor to decide which nurse she will precept. B. The nurses discuss the situation with the preceptor to come to an agreement mutually beneficial for both parties. C. One nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend. D. The nurses ignore the other nurse's request for the preceptor.

One nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend. Explanation: Accommodation involves one party deciding to let the other party win in exchange for something else of value. The nurses making an arrangement illustrates accommodation. In compromise both parties are willing to relinquish something of equal value. The nurses' decision to share the preceptor, one at the beginning of the orientation and the other one at the end of the orientation, demonstrates compromise. Each nurse ignoring the other's request illustrates avoidance. Allowing the preceptor to decide which nurse she will precept encourages competition. Competition involves a win-lose approach to conflict.

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care. Source-oriented method is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on.

A nurse manager best demonstrates effective leadership characteristic by which action? A. Sharing a vision for the unit and enlisting support B. Indicating an interest in becoming a role model C. Being very structured and rigid with the unit flow D.Knowing all information about the unit processes

Sharing a vision for the unit and enlisting support Explanation: The nurse leader on a nursing unit should have a vision for the unit and be able to share this with the staff in order to enlist support and cooperation among the staff. The nurse leader should already be a role model, rather than just demonstrating interest. This would be related more to someone who was developing leadership qualities. The nurse leader should be flexible, not rigid, and does not have to know all information about the unit; rather, the nurse leader needs to know what resources are available among the staff and other leadership in helping reach expected goals and outcomes.

Which of these statements reflects the expected functioning at a hospital that has achieved Magnet status? A. Nursing administration is in control of all decision- making. B. Most client outcomes have improved but are not at target range. C. There is a decreased rate of retention among the nursing staff. D. Staff nurses are developing innovative solutions to problems.

Staff nurses are developing innovative solutions to problems. Explanation: A hospital that has achieved Magnet status has recognition of quality client care that is provided by nursing staff who are professional and well-qualified. The staff nurses participate in self-governance and, therefore, work toward innovative solutions to problems. Having an increased turnover among staff nurses, and lack of quality client outcomes would not be characteristics of a Magnet hospital.

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve as a mentor to another staff nurse who is less experienced. Which of these would best describe this role? A. The charge nurse is being paid to supervise the staff nurse. B. The staff nurse is learning about all the hospital policies from the charge nurse. C. The charge nurse is providing support for the staff nurse in new responsibilities. D. The staff nurse is orienting to the unit as a newly hired graduate nurse.

The charge nurse is providing support for the staff nurse in new responsibilities. Explanation: A mentor is not a paid position, but, instead, is a person who provides support and encouragement to a less experienced nurse who is learning new responsibilities with their current role or an expanded one. Preceptorship typically is a paid position, and is for a new or experienced nurse who is training for a new position on a unit. The preceptor would teach the new nurse about hospital policies and procedures, as well as supervise the nurse in their daily assignments.

The new mother attempts to breastfeed the baby again using the techniques recently acquired and is successful. Explanation: Refreezing involves making the change operational. The mother feeding her baby using new techniques is an example of refreezing.

The nurse recognizes that a new mother is having difficulty breastfeeding her baby. The nurse provides assistance by demonstrating various positions to hold the baby while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the baby again using the new techniques and is successful. Which statement illustrates Lewin's stage of refreezing? A. The new mother attempts to breastfeed the baby again using the techniques recently acquired and is successful. B. The nurse provides assistance by demonstrating various positions to hold the baby while feeding. C. The nurse also educates the mother on ways to ensure proper latching. D. The nurse recognizes that a new mother is having difficulty breastfeeding her baby.

Two new graduate nurses are requesting the same preceptor for unit orientation. Both new graduates have been very vocal about being unhappy if they do not receive their choice of preceptors. Which illustrates the nurses using a compromise approach to conflict resolution? A. The nurses will allow the preceptor to decide which nurse she will precept. B. The nurses decide to share the preceptor. The preceptor will precept one nurse at the beginning of the orientation and precept the other nurse at the end of the orientation. C. The nurses ignore the other nurse's request for the preceptor. D. The nurses make an arrangement for the preceptor. One nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend.

The nurses decide to share the preceptor. The preceptor will precept one nurse at the beginning of the orientation and precept the other nurse at the end of the orientation. Explanation: Compromise involves both parties willing to relinquish something of equal value. The nurses decision to share the preceptor, one at the beginning of the orientation and the other one at the end of the orientation, demonstrates compromise. Each nurse ignoring the other's request illustrates avoidance. Allowing the preceptor to decide which nurse she will precept encourages competition. Competition involves a win-lose approach to conflict. The nurses' making an arrangement illustrates accommodation. Accommodation involves one party deciding to let the other party win in exchange for something else of value.

A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump? A. The pump compresses the tubing to infuse the solution at a precise, preset rate. B. The pump will continue to infuse fluid even when the needle is displaced. C. The pump stops pushing the fluid in the client's vein when the needle is displaced. D. The pump will sound an audible and visual alarm warning the nurse of the situation.

The pump will continue to infuse fluid even when the needle is displaced. Explanation: The nurse should be aware that an infusion pump continues to infuse fluid even when the needle is displaced. The pump continues to infuse fluid into the tissue until the machine's maximum preset pressure reaches its limit. The infusion pump adjusts the pressure according to the resistance it meets. The pump does not compress the tubing to infuse the solution at a precise, preset rate, which is done by a volumetric controller. An electronic infusion device would sound an audible alarm if the infusion container is empty, air is detected in the tubing, or resistance is met in delivering the fluid. The infusion pump does not stop pushing the fluid in the client's vein when the needle becomes displaced.

A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism? A. Droplet B. Airborne C. Direct contact D. Vehicle

Vehicle Explanation: Vehicle transmission involves the transfer of microorganisms by way of vehicles or contaminated items that transmit pathogens; for example, food can carry Salmonella. Direct contact transmission involves body surface-to-body surface contact causing the physical transfer of organisms between an infected or colonized person and an infected host. Droplet transmission occurs when mucous membranes of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, or talking. Airborne transmission occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens.

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

You Selected: remove gloves, wash hands, remove gown Correct response: remove gloves, remove gown, wash hands Explanation: The nurse will remove and dispose of the most contaminated items first, then dispose of other items, and then wash hands. Gloves should be first removed, then the gown. Then, hands are washed. Other answers are incorrect.

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? A. an adolescent who has a right radial fracture B. a school-age child who is current with immunizations C. a middle-aged adult who takes prescribed medication to control blood pressure D. an older adult client with a history of heart failure

an older adult client with a history of heart failure Explanation: Many factors affect the risk for infection, including age, sex, race, and heredity. Neonates and older adults, especially those who have pre-existing illnesses, appear to be more vulnerable to infection. School-age children are exposed to potential infections, but immunizations protect the child. An adolescent with a fracture or middle-aged adult taking medication to control blood pressure could develop an infection, but these clients are not at the highest risk.

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement? A. airborne precautions B. droplet precautions C. contact precautions D. standard precautions

contact precautions Explanation: VRE is transmitted via contact. The nurse caring for a client with VRE should implement contact precautions which is wearing a gown and gloves while in the client's room. Droplet precautions include wearing a surgical mask while in the room. Special masks for airborne precautions are used for, but are not limited to: measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium tuberculosis. Standard precautions are used with all clients.

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? A. none B. contact C. droplet D. airborne

droplet Explanation: Whooping cough is transmitted through droplets; therefore, droplet precautions are appropriate.