mastery level questions

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?

Dermis The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lieds directly beneath the epidermis.

Which terms refers to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.

In an allergic reaction, the immunoglobulin that binds to mast cells that release histamine is the:

IgE immunoglobulin response in allergic response and parasitic infections, while the IgA is the primary defense against local infections in mucosal tissues. IgG protects against bacteria, toxins and viruses, and activates the complement system. The IgD acts as an antigen receptor for initiating the B cells.

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site?

Obtain the attention of all members of the surgical team. The second verification of the surgical procedure and surgical site should be done at one time and include all members of the surgical team. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or client. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.

Which of the following is an inappropriate nursing action by the surgical nurse?

Wearing sterile gloves over artificial nails Artificial nails are prohibited in the clinical setting, because they can cause nosocomial infections.

The term used to describe total urine output less than 0.5 mL/kg/hr is

oliguria. Oliguria is associated with acute and chronic renal failure. Anuria is used to describe total urine output less than 50 mL in 24 hours. Nocturia refers to awakening at night to urinate. Dysuria refers to painful or difficult urination.

A client asks if pain threshold and pain tolerance are the same. The best response by the health care provider would be:

"Pain threshold is the point at which a stimulus is perceived as painful." Pain threshold is closely associated with the point at which a nociceptive stimulus is perceived as painful. Pain tolerance relates more to the total pain experience; it is defined as the maximum intensity or duration of pain that a person is willing to endure before the he or she wants something done about the pain. Psychological, familial, cultural, and environmental factors significantly influence the amount of pain a person is willing to tolerate. The threshold for pain is fairly uniform from one person to another, whereas pain tolerance is extremely variable.

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?

Keeping the perineal area clean and dry

Following morning hygiene of an elderly client, the nurse is unable to replace the retracted foreskin of the penis. Which is the most likely outcome?

Painful swelling Paraphimosis results in strangulation of the glans penis from inability to replace the retracted foreskin. The strangulation results in painful swelling of the glans. Erection of the penis in the presence of phimosis can cause pain but is not a result of retracted foreskin. Nausea and vomiting are not indicated with retraction of foreskin.

A nurse is assessing a client's nutritional intake during pregnancy. What is the best method for accomplishing this?

enacting a 24-hour nutrition recall Although all of the answers refer to interventions that the nurse should include in her assessment, the 24-hour nutrition recall is the best single method for assessing her nutritional intake.

How should the nurse counsel a postpartum client on how to prevent mastitis?

"Wash your hands thoroughly, and let your breasts dry after each feeding." Handwashing is one of the best ways to prevent infection. If the woman feels that her breast is warm, hard, or red, she should increase the amount of breastfeeding from that side. It is not necessary to sterilize bottles and pumping equipment after each use. Normal dish washing is sufficient. Keeping the breasts exposed to the air to dry will aid in preventing infection.

The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan?

Data gathering, identification of client strengths, and assurance of client safety during the assessment phase Establishment of priorities, identification of problems and risks, and delegation and management of client care are all roles of the registered nurse during the nursing process. Data gathering, identification of client strengths, performance of assessments and assurance of client safety are role of the LPN when using the nursing process to develop the client plan of care.

The nurse is caring for a client who has produced an average of 20 mL/hour for the previous day. The nurse recognizes this compares in which way to the normal urine output?

The kidneys should produce about 1.5 L of urine each day. The kidneys normally produce approximately 1.5 L or 1500 ml of urine each day.

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:

Survival adaptation An example of adaptation for survival is the development of antibiotic-resistant bacterial strains of Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae. Bacterial resistance is not demonstrated by aerobic activity. Spore production is another form of adaptation. Means of transmission is a component of the chain of infection, not an example of bacterial resistance.

A nurse prefers to use an alcohol-based hand rub when providing care for clients. In which case is this practice contraindicated?

The nurse is caring for a client with a C. difficile infection. Controversy exists regarding the use of alcohol-based hand rubs when C. difficile organisms have been identified. Alcohol does not kill C. difficile spores.

Which type of macrophages are found in the liver?

Macrophages found in the liver are known as Kupffer cells. Histiocytes are macrophages found loose in connective tissue, and microglial cells are brain macrophages. Monocytes are referred to macrophages when they enter the tissues.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Take the restraints off, stay with her, and talk gently to her. Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition—not confusion and agitation—dictates when the client is discharged.

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?

Apply ice. Ice is applied to perineal edema within 24 hours after birth. Use of ointments is not advised for perineal edema. Moist heat and a sitz or tub bath are encouraged if edema continues 24 hours after birth.

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?

Cooperation by the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.

The nurse is assisting in the development of a protocol for bladder retraining following removal of an indwelling catheter. Which item should the nurse include?

Implement a 2- to 3-hour voiding schedule Immediately after the removal of the indwelling catheter, the client is placed on a voiding schedule, usually 2 to 3 hours. At the given time, the client is instructed to void. Immediate voiding is not usually encouraged.

The nurse is completing the admission assessment on a client with renal failure. The client states, "I was diagnosed with impetigo yesterday." Which is the appropriate nursing intervention?

Initiate contact isolation protocol. Impetigo is a bacterial infection transmitted via contact. Therefore, the nurse should initiate contact isolation protocol. The client would not be taking an antiviral medication for impetigo, would not need a negative-pressure room, and would not wear a mask when outside the room.

A patient comes into the clinic frequently with complaints of pain. What would the nurse recognize as chronic benign pain in a patient?

Low back pain Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life. Examples of noncancer pain include peripheral neuropathy from diabetes, back or neck pain after injury, and osteoarthritis pain from joint degeneration.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

The nurse is teaching the family of a client diagnosed with leukemia about ways to prevent infection. Which instruction has the most impact?

maintaining an intact skin integrity A client with leukemia has a compromised immune system. Maintaining skin integrity is a priority as the skin is a barrier to pathogens. If a pathogen enters the client's system, the client may not be able to fight off the bacteria and it will multiply and spread. Bathing daily can decrease bacteria on the skin but unless there is a break in the skin, the bacteria will remain on the skin. Covering the mouth when coughing protects others but does not have an impact on the client. Ingesting a plant-based diet may be nutritious, which helps the immune system; but, this does not have the most impact.

For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep?

playing soft or soothing music Playing soft or soothing music promotes relaxation, which fosters rest and sleep. To promote sleep, the nurse should also encourage the client to increase activity during the day, avoid providing stimulating beverages (such as caffeinated coffee) in the evening, and offer an evening snack with warm milk. The nurse should also encourage the client to decrease activity 2 hours before bedtime to promote sleep.

An infection or the products of infection carried throughout the body by the blood is called:

septicemia Transport of an infection or the products of infection throughout the body by the blood is known as septicemia. Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection.

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?

to clear secretions from the tubing The picture shows a nurse inserting the suction catheter in a container of water. The hole on the catheter is then occluded creating suction. The water is used to clear the catheter and tubing of secretions. The tubing does not need to be primed or lubricated. The catheter removes the secretions but does not loosen them.

A 63-year-old male patient has just begun treatment with IV paclitaxel. About 10 minutes into the infusion, the nurse becomes concerned about a possible anaphylactic reaction to the drug because the patient is experiencing:

Dyspnea, hypotension, tachycardia, wheezing, and chest pain are manifestations of anaphylactoid reaction. This hypersensitivity reaction usually occurs during the first 20 minutes of the infusion and happens on the first or second exposure to the drug. Increased body temperature is not associated with an anaphylactoid reaction.

When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation?

Engage safety shield on needle guard and discard needle appropriately. The needle needs to be disposed of properly after engaging the safety guard because the needle cannot be reinserted due to contamination. A new needle can be attached to the syringe and the remainder of the medication administered after cleansing the site again. The incident does warrant notifying the primary care provider.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough Formula in the mouth and cough are indicators of aspiration. Passage of flatus reflects intestinal motility, which does not pose a potential problem. A passage of flatus is not reflected in tolerating a feeding, it is an indication of bowel function. A rapid flow should not be administered by a nurse, and gastric tenderness does not indicate tolerance of tube feed.

A client tells a nurse that she's going to breast-feed her neonate but she isn't sure what she should eat. Which client statement requires further teaching?

"I'll take all the same medications I was taking before my pregnancy." The client indicates she needs additional teaching when she states she'll resume taking all the medications she was taking before her pregnancy because most drugs are excreted through breast milk and may affect the neonate. The client should consult with her physician before taking any drugs while breast-feeding. She should increase her daily calories by 500, drink 10 glasses of fluid, and include milk products in her diet to increase her milk production and provide adequate nutrition for her neonate and herself.

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?

Decontaminate hands using an alcohol-based hand rub. Alcohol-based hand rubs can be used if hands are not visibly soiled. If the hands are visibly soiled, the nurse should wash hands with soap and hot water. The nurse should wash their hands. The nurse does not need to wash their hands AND use an alcohol-based hand rub.

A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?

Clinical nurse specialist Clinical nurse specialists are nurses with an advanced degree who are considered experts in a specialized area of care. They also provide direct care, consultation, and education of clients, families, and staff. Nurse managers do not normally provide direct care. Nurse-midwives specialize in obstetrical care. Physician assistants are not nurses.

After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence?

Decreased pelvic muscle tone due to multiple pregnancies Stress incontinence is due to decreased pelvic muscle tone, which is associated with multiple pregnancies, obstetric injuries, obesity, menopause, or pelvic disease. Transient incontinence is due to increased urine production related to metabolic conditions. Urge incontinence is due to bladder irritation related to urinary tract infections, bladder tumors, radiation therapy, enlarged prostate, or neurologic dysfunction. Overflow incontinence is due to obstruction from fecal impaction or enlarged prostate.

The nurse is assessing a client who has a small pinpoint rash. What is the best cause of this rash?

Pinpoint petechiae Small pinpoint spots are usually petechiae. Lesions are traumatic or pathologic loss of normal tissue structure and would not be appropriate to document as a rash.

A geriatric client is observed smoking a cigarette and lowering the oxygen nasal prongs away from the nostrils. Which is the priority action of the nurse?

Remind the client to avoid smoking during oxygen therapy There is a highly flammable risk when cigarettes are lit and smoked near oxygen therapy. Both the clients and guests should be advised and reminded not to smoke when oxygen therapy is present. Although tobacco chewing would lessen the flammable risk, this product is infrequently available. The nurse should discuss smoking habits and the interest to quit smoking cigarettes with the client. If the client expresses interest in a smoking cessation program or, even, the nicotine treatments, then it would be appropriate for the nurse to request a smoking cessation prescription from the physician. However, the nurse should always consider and discuss the client's preferences and coping mechanisms rather than institutionally pressuring or assimilating the client to stop smoking. Finally, while every client will die one day from medical diseases or accidents, the nurse must recognize the flammable risk the client is generating to him- or herself, those around them, and the surrounding environment. The nurse has a moral responsibility to remind the client of the flammable risks of mixing oxygen with cigarette smoking.

A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate?

The client will likely not be able to sleep. The expectation that the onset of sleep will be difficult increases the person's anxiety. The anxiety floods the brain with stimulating chemicals that interfere with relaxation, which is a prerequisite for natural sleep. Given the client's anxiety about the surgery, as well as the expectation that they will not sleep, it is likely that the client will not be able to sleep. Worry may cause exhaustion, but it will not cause the client to fall asleep quickly. Since the client will likely not sleep, the nurse does not anticipate patterns of wakening for the client.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?

perform hand hygiene before and after entering the client's room Hand hygiene is the most important way to prevent transmission of infection.

A client who is receiving drug therapy for treatment of giardiasis asks the nurse about how she may have gotten this infection. The nurse would incorporate knowledge of transmission into what assessment question?

"Have you drunk any water that might have been contaminated?" Giardiasis is transmitted by the ingestion of contaminated water or food. Trichomoniasis typically is transmitted by sexual intercourse with men who have no signs and symptoms of the infection. Malaria is transmitted by a mosquito bite. Family history of illness is relevant, but the main variable is intake of contaminated water.

Which intervention should a nurse perform after administering an injection of penicillin to a client with an infection?

After administering injections of penicillin, the nurse should make the client wait at least 30 minutes before allowing him or her to leave the health care facility. This is because allergic reactions are frequent and can be severe enough to be fatal. It is not essential for the client to avoid fluid or food intake or to lie down for 4 hours after receiving penicillin.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?

The nurse keeps fingernails less than 1/4 in (0.63 cm) long. The nurse needs to keep fingernails less than 1/4 in (0.63 cm) long. Gloves should never be used in place of hand hygiene. Gloves should always be worn when the nurse is in contact with blood. The nurse could use a hospital sanctioned hand moisturizer after hand hygiene, but this is not the best answer.

A client is placed on a low-sodium (500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective?

"I chose broiled chicken with a baked potato for dinner." 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, sardines, and bouillon are extremely high in sodium and shouldn't be included in a low-sodium diet.

The nurse is conducting discharge teaching for a caregiver and a toddler. Which statement by the caregiver indicates the need for additional teaching?

"I will check my text messages while my child is in the tub." Toddlers should not be left in a tub unattended for risk of drowning. Toddlers can easily slip under water even in the time it takes to check a text message. Using a three-point seatbelt, learning CPR and ensuring toys and balls are not smaller than a tennis ball are correct actions for prevention of accidental injury in a toddler.

Which is the most likely weaponized biological agent available?

Anthrax Anthrax is recognized as the most likely weaponized biologic agent available. Anthrax is caused by replicating bacteria that release toxins, resulting in hemorrhage, edema, and necrosis. The plague, smallpox, and botulism are not the most likely weaponized biological agents available.

While reviewing a client's history, an allergy to which of the following would alert the nurse to a possible problem with the use of ipratropium?

Peanuts The use of ipratropium is contraindicated in the presence of known allergy to the drug or to peanuts or soy products because the vehicle used to make ipratropium, an aerosol, contains a protein associated with peanut allergies.

The nurse working at a community clinic is caring for a young male client. The client asks the nurse if he could get AIDS from being sprayed in the face with breast milk. Select the best response by the nurse.

"Breast milk can contain the virus that causes AIDS, but to be infected, the milk needs to be in contact with your mucous membranes or an open sore." HIV can be transmitted through breast-feeding; however, transmission requires contact with mucous membranes or an open sore.

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety?

"Place the walker directly in front of you and step into it as you move it forward." When the client places the walker directly in front of them, they create a stable base for forward movement and reduces the likelihood of falls. The client shouldn't set the back leg down first because this creates an unstable base that could lead to a fall. The client should firmly grip the side bars; doing so provides a more stable base of support than gripping the front bar. The nurse shouldn't suggest that the client use a walker with wheels. Only a physician or physical therapist may order a walker with wheels.

A client recently experienced a stroke with accompanying left-sided paralysis. The family voices concerns about how to best interact with the client. They report the client doesn't seem aware of their presence when they approach the client on the left side. What advice should the nurse give the family?

"The client is unaware of their left side. You should approach them on the right side." The client is experiencing unilateral neglect and is unaware of their left side. The nurse should advise the family to approach on the nonaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.

A new mother asks her nurse about the safety of taking St. John's wort for postpartum depression. What would be the nurse's best response?

"There is insufficient evidence to support the use of St. John's wort, and drug interactions may be extensive." Most experts agree that there is insufficient evidence to establish that St. John's wort is effective in treating depression. The herb has some side effects (such as photosensitivity, dizziness, and nausea), though they are usually infrequent and mild. Drug interactions, however, may be extensive. St. John's wort may decrease the effectiveness of some drugs, and combining it with others, such as cold and flu medications, may result in severe hypertension.

A client from a minority culture has been hospitalized for 6 days for postoperative infection. The client's weight is decreasing each day, and the nutritional intake is declining. Which nutritional assessment question is most appropriate?

"What type of food do you eat at home?" Cultural food preferences often put the client at risk for inadequate nutrition. By exploring what foods the client eats at home, the nurse can assess the client's cultural dietary preferences and work to incorporate these foods into the meal plan. The other choices are judgmental and indicate that the client should eat what is presented regardless of cultural preference.

The kidneys receive approximately what percentage of the cardiac output?

25%

The nurse is caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. The nurse knows that these clients would be classed as being victims of which of the following?

A biologic disaster Anthrax is a biologic agent that could be the cause of a biologic disaster, one in which pathogens or their toxins cause harm to many humans and other living species. Anthrax is not a natural, radiologic, or chemical agent of disaster.

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission?

A child quickly removing a hand when touching a hot object Transduction, the first process involved in nociception, refers to the processes by which a noxious stimulus, such as a burn, releases of a number of excitatory compounds, which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual-mechanism analgesic agent, such as tramadol, involves many different neurochemicals as in the process of modulation.

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV). CMV exposure can affect the fetus; women who are pregnant should avoid contact with CMV-positive clients. HIV is transmitted via blood and body fluids; all staff should take contact precautions. When a mother has gonorrhea, a nurse should administer eye prophylaxis to the neonate to prevent neonatal ophthalmic infection. It isn't a concern for staff. Erythema toxicum is a common rash in infancy; communicability isn't a concern.

While assessing a client, the client tells the nurse that he is a follower of traditional Chinese medicine and the concept of qi. Based on the nurse's understanding of this concept, which treatment modality would the nurse expect the client to mention?

Acupuncture Acupuncture is based on energy regulation of qi through meridians. It is a core principle in traditional Chinese medicine. Therapeutic Touch (TT) is not a form of traditional Chinese medicine and is based on the consciously directed process of energy exchange. Physiotherapy and allopathy are not based on the concept of qi.

A 3-year-old child who was burned severely in a car accident is getting near the end of the basic healing of their wounds and needs to have her dressing changed. To help this toddler develop a sense of autonomy, which intervention may the nurse encourage the child to perform during the dressing change?

Allow the child to put the tape in place at the end of the sterile dressing change. For the child with a wound that needs changing, allow the child to hold pieces of tape or put tape in place to maintain sense of control. The child can remove an old bandage if it is not contaminated. Allow the child to view their wound and watch dressing changes, explaining each step of a procedure as you perform it helps the child maintain control. Excess supplies should be removed from the room after a procedure or the child may "redo" the dressing.

Some members of the population are so sensitive to certain antigens that they react within minutes by developing itching, hives, and skin erythema, followed shortly thereafter by bronchospasm and respiratory distress. What is this near-immediate reaction commonly known as?

Anaphylactic reaction Anaphylaxis is a systemic, life-threatening hypersensitivity reaction characterized by widespread edema, vascular shock secondary to vasodilation, and difficulty breathing. It is not called an antigen reaction or an Arthus reaction.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.

A nurse would anticipate instituting contact precautions for a client with which of the following?

Contact precautions would be appropriate for a client with an infection due to Clostridium difficile. Airborne precautions are appropriate for clients with measles or varicella. Droplet precautions are appropriate for clients with mumps.

Which verbal cue refers to accents on words or phrases that highlight the subject or give insight on the topic?

Emphasis Emphasis refers to accents on words or phrases that highlight the subject or give insight on the topic. Tone can indicate whether someone is relaxed, agitated, or bored. Pitch carries from shrill and high to low and threatening. Intensity is the power, severity, and strength behind the words.

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?

Encourage the client to drink liberal amounts of fluids The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.

A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?

Encouraging intake of at least 2 L of fluid daily Encouraging a daily fluid intake of at least 2 L helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.

A client who is legally blind had orthopedic surgery 3 days ago and wants to urinate. She is using a walker for ambulation. It would be best for the nurse to

Guide the client's hand to the armrest on the bedside commode prior to the client sitting on the commode. When the nurse offers seating to a client with low vision or blindness, the nurse should place the client's hand on the arm of the chair. This helps to guide the client in sitting. Though placing the bedside commode next to the bed is a good idea, it is not the best choice. The nurse will encourage the client to use the bedside commode, not the bedpan, for better emptying of the urinary bladder.

A client reports urinary frequency, urgency, and dysuria. Which of the following would the nurse most likely suspect?

Infection Frequency, urgency, and dysuria are commonly associated with urinary tract infection. Hesitancy and enuresis may indicate an obstruction. Oliguria or anuria and proteinuria might suggest acute renal failure. Nocturia is associated with nephrotic syndrome.

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose an example of chronic pain.

Intervertebral disk herniation Chronic pain is found with degeneration or traumatic conditions and can sometimes be the cause of the patient's primary disorder. The other three choices refer to acute pain.

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity For a client who sits for prolonged periods, such as in a wheelchair, the ischial tuberosity would be highly susceptible to pressure ulcer development. Areas such as the greater trochanter and lateral malleous would be susceptible for clients lying on their side. The scapula would be considered a high risk area for clients lying on their back.

The nurse recognizes which statement is true of chronic pain?

It may cause depression in clients. Chronic pain may lead to withdrawal, depression, anger, frustration, and dependency. Clients have difficulty describing chronic pain because it may be poorly localized. Moreover, health care personnel have difficulty assessing it accurately because of the unique responses of individual clients to persistent pain. Chronic pain is commonly characterized by periods of remission and exacerbation.

A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse?

Obtain a medical order. Nurses must obtain a medical order before each and every instance in which they use restraints. Due to the severity of the client illness requiring endotracheal intubation, the client may not be able to provide a written consent. The client does not need to be sedated unless medically necessary, and although it is appropriate to notify the family, this is not the priority.

The nurse is reviewing lab work prior to shift handoff on a client with a subnormal urine output. Which is the nurse most correct to report?

Oliguria A subnormal urine output is termed as oliguria. Polyuria is the excessive or abnormally large production of urine. Pyuria is the presence of pus in the urine. Glycosuria is the excretion of glucose in the urine.

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?

Oxygen supports combustion. Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post "No Smoking" signs when oxygen is in use, particularly in facilities that are not smoke free.

The nurse is discussing dietary intake with the parents of a 4-year-old child who has been diagnosed with atopic dermatitis. Later, the nurse notes the menu selection made by the parents for the child. Which selection indicates the need for further instruction?

Peanut butter and jelly sandwich Atopic dermatitis is commonly associated allergies to food. Common culprits may include peanuts, eggs, orange juice, and wheat-containing products

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition?

Peptic ulcers Chronic gastritis caused by Helicobacter pylori is implicated in the development of peptic ulcers. Chronic gastritis is sometimes associated with autoimmune disease, such as pernicious anemia, but not as a cause of the anemia. Chronic gastritis is not implicated in system infections and/or colostomies.

During a discussion on cellular components and their function, a student asked the instructor the purpose of messenger RNA (mRNA). Of the following, which is the most accurate answer?

Performs an active role of protein synthesis, where mRNA molecules direct the assembly of proteins on ribosomes to the cytoplasm. The nucleus is the site for the synthesis of 3 types of RNA that move to the cytoplasm and carry out the actual synthesis of proteins. Messenger RNA copies and carries the DNA instructions for protein synthesis to the cytoplasm. Ribosomal RNA is the site of actual protein synthesis; transfer RNA transports amino acids to the site of protein synthesis.

When describing the process used by the esophagus for motility, which would the nurse include?

Peristalsis The esophagus uses peristalsis to move food forward. Churning occurs in the stomach. Mass movement with an occasional peristaltic wave occurs in the large intestine. The small intestine uses a process of segmentation with an occasional peristaltic wave to clear the segment.

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair?

Protein Protein is the nutrient important for overall tissue repair. Vitamin C promotes collagen synthesis and supports the integrity of the capillary wall. Water is important to maintain homeostasis. Zinc sulfate acts as a cofactor for collagen formation.

A new client in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis?

Provide an opportunity for the client to talk about concerns. Stress and anxiety interfere with a person's ability to relax, rest, and sleep. The client is scheduled for a surgical procedure in the morning. The nursing diagnosis addresses this particular concern. Providing an opportunity for the client to talk about concerns and issues would be beneficial. The other options are incorrect because the options do not address the situation at hand, or the nursing diagnosis that is noted.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

A client who has a problem with incontinence loses a small amount of urine every time she coughs or sneezes. This type of incontinence is known as:

Stress Stress incontinence is the involuntary loss of urine associated with activities such as coughing and sneezing. Urge incontinence is the urgency and frequency associated with hyperactivity of the detrusor muscle. Overflow incontinence is the involuntary loss of urine when intravesicular pressure exceeds maximal urethral pressure. Functional incontinence is the lack of cognitive function to go to the bathroom.

The nurse is caring for a client with dysrhythmia. What would be an important procedure to teach a client with dysrhythmia to perform to evaluate his or her response to treatment?

Technique for palpating and counting the radial pulse The nurse should teach the client the technique for palpating and counting the radial pulse. An accurate pulse assessment helps the client evaluate his or her response to treatment measures. Monitoring drug toxicity, cardiac response, and blood pressure will not help a client with dysrhythmia to evaluate his or her response to treatment measures.

A preschool-age child is admitted for complaints of abdominal pain and vomiting. What is the best method for the nurse to collect data about the pain level of the child?

The Wong-Baker FACES scale The Wong-Baker FACES scale is best for pediatric, culturally diverse, and mentally challenged clients. It uses pictures and short descriptive phrases. The preschool-age child would have difficulty understanding the meaning of numbers in relation to pain. Asking the child to describe the pain does not give information about the level of pain the child is experiencing. Because the preschool child has a limited vocabulary, a word scale would not be appropriate for the rating of pain.

A nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which action would pose a threat to the client?

The client wears a watch. During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI, but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field.

The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?

This is a technique to prevent the painful stimuli from entering the brain. Gate control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location.

Which category of triage encompasses clients with serious health problems that are not immediately life threatening?

Urgent Urgent clients have serious health problems that not immediately life threatening. They must be seen within 1 hour. Emergent clients have the highest priority with life-threatening conditions and they must be seen immediately. Nonurgent clients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast-track clients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

Which of the following would be incorporated as a teaching strategy for a hearing-impaired person?

Use slow, directed, and deliberate speech When teaching persons with a hearing impairment, the nurse should use slow, directed, and deliberate speech. Use of large print materials, arrangement of materials in a clockwise position would be used for persons with a visual impairment. Demonstrating information and having the person perform a return demonstration would be appropriate for a person with a developmental disability.

The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?

Usual pattern of elimination Constipation has many possible reasons and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts?

applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

The primary source of microorganisms for catheter-related infections are the skin and the

catheter hub The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.

The nurse is preparing the client newly diagnosed with peripheral arterial disease for discharge with the medication atorvastatin. What laboratory work should the nurse obtain to establish a baseline before starting the medication?

creatinine level and liver function tests Atorvastatin has serious adverse reactions of hepatotoxicity and acute renal failure, so it is recommended that creatinine level and liver function tests be performed at baseline as a monitoring parameter. Diabetes, upper respiratory infections, urinary tract infections, anemia, and thrombocytopenia can also be adverse reactions, but these are not included in recommendations for baseline safety monitoring.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to

decrease catabolism. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to:

divide daily food intake into five or six meals. To combat fatigue, the nurse should advise the client to divide her daily food intake into five or six meals eaten throughout the day to minimize the energy expenditure associated with consuming three larger meals. Exercising before meals would increase fatigue, interfering with the client's nutritional intake. Vitamin and mineral supplements are appropriate for anyone, not specifically pregnant clients, and have little effect on fatigue.

A client is ordered continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged I.V. pole. The nurse then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow?

evaluating patency of the drainage lumen The nurse should evaluate patency of the drainage tubing before leaving the client's room. If the lumen is obstructed, the solution infuses into the bladder but isn't eliminated through the drainage tubing, a situation that may cause client injury. Balancing the pole is important; however, the nurse would have had to address this issue immediately after hanging the 2 L bag. Using an I.V. pump isn't necessary for continuous bladder irrigation. Unless specifically ordered, obtaining a urine specimen before beginning continuous bladder irrigation isn't necessary.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

high-protein Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends

increasing the amount of bran and fresh fruits and vegetables Constipation is a common problem with the use of opioid medications, such as methadone. Activities to prevent constipation include increasing bran and fresh fruits and vegetables in the diet. The client should ingest 8 to 10 glasses of fluids per day. Milk of magnesia may be used if no bowel movement is produced in 3 days. Milk of magnesia is not to be used daily. A glycerin suppository, not bisacodyl, may be used to make the bowel movement less painful.

A client admitted to the hospital with abdominal pain, anemia, and bloody stools reports feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help them:

onto the bedpan. A client who's dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up.

Rotation of the forearm so that the palm of the hand is down is termed

pronation. Pronation is the rotation of the forearm so that the palm of the hand is down. Inversion is movement that turns the sole of the foot inward. Supination is rotation of the forearm so that the palm of the hand is up. Eversion is the return movement from flexion.

A client is scheduled for a renal arteriogram. No allergies are recorded in the client's medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used?

pruritus The nurse should be alert for pruritus, which may indicate a mild anaphylactic reaction to the arteriogram dye. The client would have an increased respiratory rate. Nausea would be more likely with a food allergy or intolerance and would not be associated with a reaction to the dye. Psoriasis is a chronic condition triggered by a hyperimmune response.

Which of the following objects poses the most serious safety threat to a 2-year-old client in the hospital?

side rails in the halfway position Side rails in the halfway position pose the biggest threat because the most common accidents in hospitals are falls. To prevent falls, the crib rails always should be raised and fastened securely unless an adult is at the bedside. Crayons and paper and a stuffed teddy bear are safe toys for a 2-year-old client. Although a mobile could pose a safety threat to this client, the threat is less serious than that posed by an incorrectly positioned side rail.

A client reports swelling and severe pain in the right wrist. After examination and radiographs negate a fracture, what would the physician likely prescribe as treatment?

splint The client would use a splint when a musculoskeletal condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment.

A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?

the client's pain based on a pain rating The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, but which are not more important than the pain rating. Pain relief after nursing intervention is appropriate, but is a part of evaluation.

A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should:

turn him frequently. The most important intervention for maintaining skin integrity is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and pressure ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

All people who have household or face-to-face contact with the client diagnosed with smallpox after the fever begins should be vaccinated within what time frame to prevent infection and death?

4 days All people who have household or face-to-face contact with the client after the fever begins should be vaccinated within 4 days to prevent infection and death.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment. A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

A cloth chest restraint has been presecribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?

Check the extremities for circulation based on hospital protocols. Assessment of extremities is essential for distal blood flow. Professional responsibility is to follow policies and procedures by the hospital. Family presence can lessen confusion, tied knots do not allow for quick release in an emergency situation, and documentation of a client in this acute state needs to occur more often than once per shift.

Which method is reliable for identifying a preschooler before administering a medication?

Check the hospital identification bracelet. The only safe method for identifying the child is to check the identification band for the client's name and medical record number and then compare that information with the medication record. Children sometimes exchange beds during play, so checking the name on the bed isn't reliable. Infants are unable to give their names, toddlers, or preschoolers may admit to any name, and school-age children may deny correct identities in an attempt to avoid the medication. Parents aren't always at the bedside, so the nurse shouldn't be relied on parents for identification.

A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate?

Make sure all medications are kept in containers with childproof safety caps. Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline because poisoning accidents are common in toddlers owing to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not a seat belt. A seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers should not be allowed in the road unsupervised.

A client taking abacavir has developed fever and rash. What is the priority nursing action?

Report to the health care provider. Fever and a rash could be indicative of a hypersensitivity reaction. Hypersensitivity reactions are also known as anaphylactic reactions and often involve skin rashes, fever, and bronchopulmonary issues such as bronchial constriction. The health care provider should be notified immediately and the medication stopped. Interventions need to be taken to assure that the client's airway is not compromised. Administering acetaminophen and documentation and treating the rash are not the priority and would be completed after the client is stabilized.

A nurse is performing a home visit for a client who received chemotherapy within the past 24 hours. The nurse observes a small child playing in the bathroom, where the toilet lid has been left up. Based on these observations, the nurse modifies the client's teaching plan to include:

chemotherapy exposure and risk factors. The raised toilet lid exposes the child playing in the bathroom to the risk of inhaling or ingesting chemotherapy agents. The nurse should modify her teaching plan to include content related to chemotherapy exposure and its associated risk factors. Because the client has received chemotherapy, the plan should already include information about expected adverse effects, signs and symptoms of infection, and reinforcement of the medication regimen.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply?

decreasing environmental stimulation This client is at increased risk for injuring self or others. Decreasing environmental stimulation, a measure the nurse may take independently, may reduce the client's hyperactivity. Providing adequate hygiene is an appropriate nursing intervention but isn't the highest priority. Because the overall goal is to reduce the client's hyperactivity, orientating him to unit activities is contraindicated. Asking the client to go eat a meal in the day room is contraindicated because there is risk for harm to self or others and it is likely there will be more stimulation in the day room.

During a description of immune function, the nurse has explained how macrophages are able to engulf a pathogen in order to destroy it. The nurse is describing what aspect of cellular physiology?

endocytosis The process described is phagocytosis, which is an example of endocytosis. This does not constitute active transport or passive transport. It is one of the many processes that help maintain homeostasis, but that is not the specific process.

Diagnostic testing has resulted in a diagnosis of small cell lung cancer (SCLC) in an older adult client. When exploring the etiology of the client's disease, what assessment question is most relevant?

"Have you ever been a smoker?" Most cases of SCLC are attributable to smoking, and it is rare among nonsmokers. Family history and radiation exposure are relevant risk factors, but smoking exceeds their importance. Smoking also causes COPD, but COPD is not an independent risk factor for smoking.

A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

"If I notice tingling in my lips or mouth, gargling may help the symptoms." The client requires further teaching if they state they will gargle to help alleviate tingling in the lips or mouth. Allergy testing introduces potentially irritating substances to the client. Tingling in the mouth, lips, or throat indicates the onset of a severe reaction and the need for immediate medical intervention. The testing may cause irritation and itching at the test site. The physician may order an epinephrine pen for the client to self-administer epinephrine if they experience an allergic reaction away from the office setting.

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients' items. Pediculosis is an infestation of lice. The nurse will plan to launder linens, gowns, and bath items separately from items of other clients to prevent the transmission of infection. The other actions are not interventions the nurse would provide

The nurse is on a community awareness safety committee. When prioritizing biological agents according to potential morbidity and mortality, which cluster of biological agents hold the highest mortality?

Anthrax, smallpox The cluster of agents with the highest mortality includes anthrax and smallpox. The Hantavirus and tuberculosis agents are not presently used for bioterrorism. Botulism and Salmonella as well as Escherichia coli and Brucella species are of low mortality.

A hospitalized client states that the client is having difficulty resting. Which intervention would help promote rest?

Assisting the client with deep-breathing exercises Deep-breathing exercises are beneficial to promoting rest as they help the client to relax. The client's door should be closed to reduce noise and distractions. Tea contains caffeine, which acts as a stimulant. While sedatives may be used occasionally for assistance with rest, regular use isn't advised because dependence may develop.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?

Create an area for sterile field and opening packages Pathogens require a portal of entry to cause infection. Insertion of an indwelling urinary catheter is a sterile technique; any contamination could cause a portal of entry. Using water-soluble lubricant on catheter tip prior to insertion is correct but will not prevent an infection nor will closing the opening port. Likewise, washing the perineal area with soap and water will reduce microorganisms but will not prevent infection alone.

A patient is planning to use a negative-pressure (vacuum) device to maintain and sustain an erection. What should the nurse caution the patient about with the use of this device?

Do not leave the constricting band in place for longer than 1 hour to avoid penile injury. Negative-pressure (vacuum) devices may also be used to induce an erection. A plastic cylinder is placed over the flaccid penis, and negative pressure is applied. When an erection is attained, a constriction band is placed around the base of the penis to maintain the erection. To avoid penile injury, the patient is instructed not to leave the constricting band in place for longer than 1 hour.

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company?

Fit all employees with protective masks. The primary focus is prevention, with frequent examination of those who work in areas of highly concentrated dust or gases. Laws require work areas to be safe in terms of dust control, ventilation, protective masks, hoods, industrial respirators, and other protection. Workers are encouraged to practice healthy behaviors, such as quitting smoking. Adequate breaks, giving workshops, and providing smoking cessation materials do not prevent occupational lung diseases. Reference:

A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan?

Follow the formal written plan of action for coordinating the response of the hospital staff. When a disaster occurs, a formal written plan of action is put into place. All nurses will follow the formal plan of action. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan will focus on having health professionals and supplies available.

A community health nurse goes on a first home visit to complete a home safety assessment. Which of the following components will be part of the nurse's home safety assessment? Select all that apply.

Hard wood floors in the dining room Motion light on the porch ABC fire extinguisher in the kitchen pantry The home nurse would check the exterior and interior physical facilities and identify any safety hazards (eg, lighting and flooring concerns) and check for safety measures (eg, fire extinguisher). The nurse would not focus on the type of milk the client uses and would not be concerned about exercise equipment.

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions. The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.

Limit setting is most appropriate in which client population?

Manic

A combat veteran with posttraumatic stress disorder has been admitted to the psychiatric unit after consuming a large number of antidepressants and drinking half a quart of whiskey 2 days earlier. What aspect of care should the nurse prioritize?

Monitoring the client for suicidal ideation It is imperative to establish a therapeutic relationship with clients and to enlist their social support network. However, the client's risk of suicide is a priority because of the immediate safety implications. Affirming the client is important, but safety is a priority.

A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?

Offer a face mask to the person with the cold and use this as an opportunity for further teaching. Offering a face mask is the best approach; it protects the child while supporting the family and using the situation as an opportunity for learning. Instructing family members that it isn't healthful to share food and to avoid the child if they're sick are technically correct, but these responses don't include a rationale that enables the family to understand why these actions are important. The nurse should have posted an isolation sign on the child's door long before the time of the child's discharge.

The nurse is instructing on bioterrorism agents. Which of the following does the nurse emphasize as an agent which is transmitted from person to person?

Smallpox Smallpox is highly contagious and caused by a variola virus. Individuals infected with the botulinum toxin and anthrax are not at risk to others; there are no reports of person to person transmission. Varicella, commonly called the chickenpox, is contagious but not a bioterrorism agent.

The nurse screens a client prior to a magnetic resonance angiogram (MRA) of the heart. Which action should the nurse complete prior to the client undergoing the procedure? Select all that apply.

Remove the client's Transderm Nitro patch. Offer the client a headset to listen to music during the procedure. Remove the client's jewelry. Transdermal patches that contain a heat-conducting aluminized layer (e.g., NicoDerm, Androderm, Transderm Nitro, Transderm Scop, Catapres-TTS) must be removed before MRA to prevent burning of the skin. A client who is claustrophobic may need to receive a mild sedative before undergoing an MRA. During an MRA, the client is positioned supine on a table that is placed into an enclosed imager or tube containing the magnetic field. Clients are instructed to remove any jewelry, watches, or other metal items (e.g., ECG leads). An intermittent clanking or thumping that can be annoying is generated by the magnetic coils, so the client may be offered a headset to listen to music.

The emergency department nurse is caring for clients involved in a chlorine exposure accident at a local chemical plant. The nurse is aware that permanent damage can occur to which body systems?

Respiratory The consequences of exposure to chlorine and other respiratory toxins are related to the amount, route, and length of chemical exposure. Death occurs as fluid infiltrates the pulmonary air spaces and terminal bronchioles interfering with gas exchange. Following recovery from an acute event, victims may develop chronic bronchitis and emphysema.

The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting:

Severity of the pain as judged by the patient The patient's perception of pain severity should always be the primary consideration. It forms the baseline for all management.

The nurse is instructing volunteers at an emergency bioterrorism drill about the management and medications required to combat various viruses, bacteria, and toxins. The nurse knows that the volunteers understand the instruction when they state that managing clients who exhibit symptoms of the variola virus (smallpox) includes

Smallpox is spread by droplet or direct contact and spreads rapidly. Clients exhibiting symptoms should be immediately placed in isolation.

A charge nurse learns of another nurse who has had two unsuccessful attempts at starting a peripheral IV for a child. What is the most appropriate action by the charge nurse?

Speak to the nurse about the situation and offer to start the child's IV. When starting a peripheral IV for a child, no more than two attempts at insertion should be made by one nurse. Therefore, the charge nurse should interrupt the nurse and offer to start the IV. In children, total attempts at IV insertion should be limited to four because multiple unsuccessful attempts cause the child unnecessary pain, delay treatment, and increase the risk of complications.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

To improve quality of care The primary reason to fill out an incident report is to improve the quality of care. Incident reports are not designed to be a means for disciplinary action. Incident reports are designed to identify actual or potential risks that can be iaddressed to improve quality of care. Incident reports are not intended to initiate litigation or document everyday occurrences.

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?

Whole wheat spaghetti and broccoli To promote bowel elimination, the client should consume 20 to 35 g of fiber daily. Foods high in fiber include fresh fruits and vegetables, bran, and whole grains. Cream of wheat is refined cereal and fiber has been removed from apples because of cooking. Other foods low in fiber include soda crackers, chicken noodle soup, tea, and flavored water.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:

advance both crutches. The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.

The nurse is instructing a client with cancer who is receiving chemotherapy about reporting signs of infection. Which is the most reliable early indicator of infection in a client who is neutropenic?

fever Fever is an early sign requiring clinical intervention to identify potential causes. Chills and dyspnea may or may not be observed. Tachycardia can be an indicator in a variety of clinical situations when associated with infection; it usually occurs in response to an elevated temperature or change in cardiac function.

What is the most common viral infection?

human papillomavirus (HPV) HPV infection is the most common viral infection. Millions of Americans are infected with HPV, many unaware that they carry the virus.

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves:

performing a preoperative surgical scrub for at least 3 to 5 minutes. The surgical team should perform a surgical scrub lasting at least 3 to 5 minutes before any operative procedure. Although surgical gowns may be considered sterile, surgical scrubs are considered clean rather than sterile. Jewelry harbors bacteria; team members should remove it rather than simply clean it. A surgical team member with an open wound shouldn't be involved in a procedure requiring asepsis.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

stress incontinence. Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.

A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity?

swimming in rivers or lakes When a client with HIV has moved into the AIDS phase of the infection, the client has a very low CD4 count (<200) and is at high risk for opportunistic infections. One such infection is cryptosporidia, which is caused by protozoan parasites that are often found in water. Swimming in a river or lake greatly increases the risk of this exposure. While the client should take protection to avoid pathogens or injury during the other activities listed, none are known to carry a specific risk for the client that the nurse would need to emphasize compared to the risk of cryptosporidia infection from swimming in lakes or rivers.

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful?

"I will obtain a mask from the staff and wash my hands before touching my family member." Visitors with respiratory infections need to wear a mask until their symptoms have subsided. Reuse of a disposable mask is a risk for the spread of infection. Performing hand hygiene prior to family contact is a good practice at all times especially if the client is elderly or immune compromised. Coughing and sneezing into the bend of the elbow is better than contaminating the hands; however, a mask is the best protection during an active cold. Preventing or restricting visitation may adversely affect the client's well-being.

After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first?

Kegel exercises Kegel exercises are noninvasive and are recommended as the initial intervention for incontinence. Fluid restriction is useful for the client with increased detrusor contraction related to acidic urine. Artificial sphincter use isn't a primary intervention for post-prostatectomy incontinence. Self-catheterization may be used as a temporary measure but isn't a primary intervention.

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled.

The health care provider prescribes orders for a client with newly diagnosed uncontrolled seizure activity. When reviewing the prescriptions, the nurse correctly identifies that which prescription, if followed, puts him at risk for negligence charges?

Restrain all four extremities The nurse is obligated to carry out the health care provider's orders unless it is unclear or incorrect. The client with seizures must be protected from harm. Restraints restrict the client's movement and can cause harm. Diazepam, oxygen, and frequent neurologic assessments are correct interventions for a client with uncontrolled seizure activity.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as they are harmful to the other clients. The nurse should restrain the client because they are potentially harmful to other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client but sometimes it may not be logical to wait for orders to restrain a violent client.

The nurse is preparing to defibrillate a client with no breathing or pulse. Which nursing action precedes the nurse pressing the discharge button?

Shouts, "All clear" Preceding pressing the discharge button, the nurse shouts "All clear" to ensure that no one is in contact with the client. The other options are correct but not the nursing action immediately preceding.

The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding?

The woman may be experiencing an exacerbation of right-sided HF. Increased JVP is associated with right-sided HF. Dyspnea may or may not be present, but is more closely associated with left-sided HF. Increased JVP is not necessarily indicative of impending shock.

The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child?

Following guidelines for protective isolation The child with leukemia is susceptible to infection, especially during chemotherapy. Infections such as meningitis, septicemia, and pneumonia are the most common causes of death. To protect the child from infectious organisms, follow standard guidelines for protective isolation. Grouping nursing care to provide rest is important, but not the highest priority. Encouraging the child to share feelings and providing age-appropriate activities are important, but psychological issues are a lower priority than physical.

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?

Keep hands lower than elbows to allow water to flow toward fingertips. Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wet the hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms.

A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain?

Sharp and piercing The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the patient to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.

A client with impaired hearing communicates through sign language and has been admitted to the unit before scheduled surgery. The interpreter that the hospital employs is at the bedside. The nurse needs to take what actions into consideration prior to doing preoperative teaching with this client?

The interpreter may lag a few words behind--especially if names or technical terms are to be fingerspelled. If a nurse is speaking through a sign language interpreter, the interpreter may lag a few words behind—especially if names or technical terms are to be fingerspelled. So the nurse should pause occasionally to allow the interpreter time to translate completely and accurately. The facility should provide an interpreter for the client with a disability. Family members should not serve as interpreters due to concern for misinterpretations of information and the need to maintain client privacy and confidentiality. The nurse should talk directly to the person who has hearing loss, not to the interpreter. However, although it may seem awkward, the person with hearing loss will look at the interpreter and may not make eye contact with the nurse during the conversation.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

The client must demonstrate control over his aggressive behavior so that he won't hurt himself or others or destroy property in the hospital setting. A discussion of angry feelings with the family can occur at a later time. Performing an assessment for tardive dyskinesia isn't a priority in the situation described. If the client were taking neuroleptic medication, a baseline assessment for tardive dyskinesia would already have been performed. The client's learning of effective communication and coping skills is a later goal, but not of primary importance.

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the:

sympathetic nervous system. The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.