N1 Exam 1 Treas

A clients average normal temperature is 98F. Which of the following temperatures would be expected during the night in this healthy young adult client who does not have a fever, inflammatory process, or underlying health problems? 1)97.2F 2)98.0F 3)98.6F 4)99.2F

1

At last measurement, the clients vital signs were as follows: oral temperature 98F (36.7C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2F (38.5C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurses first intervention at this time? 1)Ask the client if he has had a warm drink in the last 30 minutes. 2)Notify the primary care provider of the clients temperature. 3)Ask the client if he is feeling chilled. 4)Take the temperature by a different route.

1

For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose 1)Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg 2)Oral temperature is 97.9F in the morning and 99.8F in the evening 3)Heart rate was 76 beats/min before eating and 88 beats/min after eating 4)Respiratory rate is 16 breaths/min when standing and 18 when lying down

1

The nurse assesses the following changes in a clients vital signs. Which client situation should be reported to the primary care provider? 1)Decreased blood pressure (BP) after standing up 2)Decreased temperature after a period of diaphoresis 3)Increased heart rate after walking down the hall 4)Increased respiratory rate when the heart rate increases

1

The nurse is assessing vital signs for a client after surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to 1)Compare the left pedal pulse with the right pedal pulse 2)Count the clients respiratory rate for 1 full minute 3)Take the blood pressure in the arm without an IV 4)Take an oral temperature with an electronic thermometer

1

The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important for the nurse to 1)Ask the client to demonstrate the use of the blood pressure device 2)Explain the importance of frequent calibration of the device 3)Give the client a chart to record his blood pressure readings 4)Provide written instructions of the information taught

1

The nursing instructor asks students how they would assess the fifth vital sign. Which student would be correct? 1)I would have the client rate her pain on a scale of 0 to 10. 2)I would ask the client when she had her last bowel movement. 3)I would take the clients pulse oximetry reading. 4)I would interview the client about history of tobacco use.

1

Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count? 1)Counting the rate for 1 full minute 2)Exposing only the left side of the chest 3)Determining why assessment of apical pulse is indicated 4)Using your ring finger to palpate the intercostal spaces

1

All of the following clinical signs may be present with hypoxia. However, only two are specific indicators of hypoxia (that is, if they are present, it means that the patient is probably hypoxic). Which ones are specific indicators of hypoxia? Choose all that apply. 1)Feelings of anxiety 2)Crackles in the lung bases 3)Increased heart rate 4)Improved breathing in upright position

1, 3

Which of the following interventions would be appropriate for a client who has a fever? Choose all that apply. 1)Put an ice pack on the clients neck and axillae. 2)Provide the client a blanket when he is shivering. 3)Offer the client fluids to drink every 1 to 2 hours. 4)Take the temperature using a tympanic thermometer.

1, 3

1)High-pitched sound heard on inspiration in infants 2)High-pitched, continuous musical sound 3)High-pitched popping or low-pitched bubbling sounds 4)Low-pitched continuous sounds that clear with coughing 5)Labored, snoring sound ____ 1. Crackles ____ 2. Rhonchi ____ 3. Stridor ____ 4. Wheezes ____ 5. Stertor

1- 3 2- 4 3- 1 4- 2 5- 5

Match the nursing role listed on the left with the appropriate activity listed on the right. Each activity has only one correct answer. 1)Planning the unit's staffing schedule 2)Participating on a committee to develop a program to teach schoolchildren proper handwashing 3)Teaching the client about a scheduled test 4)Discussing new medication at a staff meeting 5)Discussing with the physician the client's reasons for not wanting the recommended surgery. ____ 1. Direct care provider ____ 2. Client advocate ____ 3. Manager ____ 4. Change agent

1.ANS:3PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 2.ANS:5PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 3.ANS:1PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 4.ANS:2PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application

Match the nursing organization with its function in the nursing profession. 1)Responsible for setting and maintaining nursing education standards 2)Developed Code for Nurses and the Standards of Clinical Nursing Practice 3)Responsible for publishing the journal, Image 4)Honor society for nursing 5)Represents nursing and promotes nursing leadership worldwide ____ 11. American Nurses Association (ANA) ____ 12. National Student Nurses Association (NSNA) ____ 13. National League for Nursing (NLN) ____ 14. International Council of Nursing (ICN) ____ 15. Sigma Theta Tau International (STTI)

11. ANS: 2 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 12. ANS: 3 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 13. ANS: 1 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 14. ANS: 5 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 15. ANS: 4 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall

A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4F (37.4C). Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the clients respiratory rate to be 1)16 2)18 3)20 4)22

2

The clients temperature is 101.1F. Which is the correct conversion to centigrade? 1)38.0C 2)38.4C 3)38.8C 4)39.2C

2

The nurse hears rhonchi when auscultating a clients lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1)Have the client take several deep breaths. 2)Request the client take a deep breath and cough. 3)Take the clients blood pressure and apical pulse. 4)Count the clients respiratory rate for 1 minute.

2

Which assessment data best support a report of severe pain in an adult client whose baseline vital signs are within an average normal range? 1)Oral temperature 100F (37.8C) 2)Respiratory rate 26 breaths/min and shallow 3)Apical heart rate 56 beats/min 4)Blood pressure 124/82 mm Hg

2

Which of the following pieces of information in the clients health history might indicate a risk for primary hypertension? 1)Consumes a high-protein diet 2)Drinks three to four beers every day 3)Has a family history of kidney disease 4)Does not engage in physical exercise

2

Which of the following sets of vital signs are all within normal limits for patients at rest? 1)Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54 2)Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 3)Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84 4)Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95

2

Which one of the following clients would probably have a higher than normal respiratory rate? A client who has 1)Had surgery and is receiving a narcotic analgesic 2)Had surgery and lost a unit of blood intraoperatively 3)Lived at a high altitude and then moved to sea level 4)Been exposed to the cold and is now hypothermic

2

When assessing the quality of a clients pedal pulses, what is the nurse assessing? Choose all that apply. 1)Rhythm of the pulses 2)Strength of the pulses 3)Bilateral equality of pulses 4)Rate compared with apical pulse

2, 3

Which of these steps in taking a blood pressure is correct? Choose all that apply. 1)Use a bladder that encircles 40% of the arm. 2)Wrap the cuff snugly around the clients arm. 3)Ask the client to hold the arm at heart level. 4)Have the client sit with feet flat on the floor.

2, 4

A client who has been hospitalized for an infection states, The nursing assistant told me my vital signs are all within normal limits; that means Im cured. The nurses best response would be which of the following? 1)Your vital signs confirm that your infection is resolved; how do you feel? 2)Ill let your healthcare provider know so you can be discharged. 3)Your vital signs are stable, but there are other things to assess. 4)We still need to keep monitoring your temperature for a while.

3

A clients axillary temperature is 100.8F. The nurse realizes this is outside normal range for this client and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1)Add 1F to 100.8F to obtain an oral equivalent. 2)Add 2F to 100.8F to obtain a rectal equivalent. 3)Obtain a rectal temperature reading. 4)Obtain a tympanic membrane reading.

3

A clients vital signs at the beginning of the shift are as follows: oral temperature 99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later the clients oral temperature is 102.2F (39C). Based on the temperature change, the nurse should anticipate the clients heart rate would be how many beats/min? 1)62 2)82 3)102 4)122

3

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most important for the nurse to include? 1)Be sure to put mittens on the baby. 2)Layer the infants clothing. 3)Place a cap on the infants head. 4)Put warm booties on the baby.

3

The nurse provides client education regarding hypertension prevention and management. Which of these statements indicates that the client understands the instructions? 1)I dont have to worry if my blood pressure is high once in a while. 2)I guess I will have to make sure I dont drink too much water. 3)I can lose some weight to help lower my blood pressure. 4)I will need to reduce the amount milk and other dairy products I use.

3

Comparing the changes in vital signs as a person ages, which statement is correct? Select all that apply. 1)Blood pressure decreases less than heart rate and respiratory rate. 2)Respiratory rate remains fairly stable throughout a persons life. 3)Blood pressure increases; heart rate and respiratory rate decline. 4)Men have higher blood pressure than women until after menopause.

3, 4

Which blood pressure has a pulse pressure within normal limits? Choose all that apply. 1)104/50 mm Hg 2)120/62 mm Hg 3)120/80 mm Hg 4)130/86 mm Hg

3, 4

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? 1)Ask the client when in the day dizziness occurs. 2)Help the client to assume a recumbent position. 3)Measure both heart rate and blood pressure with the client standing. 4)Measure vital signs with the client supine, sitting, and standing.

4

For which of the following patients would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who 1)Had abdominal surgery 2 hours ago 2)Suffered a fractured hip yesterday 3)Is dehydrated from vomiting 4)Has a heart or lung disease

4

In caring for a client who has a fever, it would be important for the nurse to monitor for increased 1)Urine output 2)Sensitivity to pain 3)Blood pressure 4)Respiratory rate

4

In evaluating a clients blood pressure for hypertension, it would be most important to 1)Use the same type of manometer each time 2)Auscultate all five Korotkoff sounds 3)Measure the blood pressure in both arms 4)Monitor the blood pressure for a pattern

4

The client has had a fever, ranging from 99.8F orally to 103F orally, over the last 24 hours. The clients fever would be classified as 1)Constant 2)Intermittent 3)Relapsing 4)Remittent

4

Match the event with the appropriate year. Each item has only one correct answer. 1)Nursing programs become affiliated with religious groups 2)Start of public health nursing with the founding of the Henry Street Settlement 3)First formal nursing education in United States 4)First hospital 5)Establishment of the Army Nursing Service 6)Disassociation of nursing from religious orders 7)Florence Nightingale cared for the soldiers of the Crimean War ____ 5. 1st-century AD ____ 6. 15th to 19th century ____ 7. 1854 ____ 8. 1861 ____ 9. 1873 ____ 10. 1893

5.ANS:4PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 6.ANS:6PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 7.ANS:7PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 8.ANS:5PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 9.ANS:3PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 10.ANS:2PTS:1DIFgrinifficult REF: pp. 6-11; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall

How will each of the errors affect a clients blood pressure reading? A. Blood pressure cuff too narrow __________________________ B. Blood pressure cuff too wide ____________________________ C. Assessing immediately after smoking _____________________ D. Assessing immediately after eating _______________________ E. Assessing when the client is in mild-to-moderate pain __________ F. Assessing when the client experiences severe pain _________________ G. Assessing immediately after exercise ______________________

A- erroneously high B- erroneously low C- temporarily high D- temporarily high E- temporarily high F- temporarily low G- temporarily high

Which of the following nursing activities represent direct care? Choose all that apply. 1)Bathing a patient 2)Administering a medication 3)Documenting an assessment 4)Making work assignments for the shift

ANS: 1 Direct care involves personal interaction between the nurse and clients (e.g., giving medications, dressing a wound, or teaching a client about medicines or care). Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing).

A patient underwent surgery 3 days ago for colorectal cancer. The patient's critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed? 1) Postpone the teaching session until the patient is more receptive. 2) Follow the critical pathway for patient teaching about ostomy care. 3) Administer a prescribed antidepressant and notify the physician. 4) Explain to the patient the importance of skin care around the ostomy site.

ANS: 1 A depressed affect and poor eye contact likely indicate that the client is having difficulty coping with the new colostomy. At this time, the client would not be physically and psychologically ready to obtain the most benefit from teaching pertaining to ostomy care. Therefore, the nurse should postpone the teaching session for this client until the client is receptive to receiving the information. The nurse should not perform the teaching session simply because the critical pathway indicates it is appropriate. Simply administering an antidepressant does not address the client's readiness to participate in a teaching session and ultimately self-care of the ostomy. The nurse should encourage the client to verbalize his feelings. Client education is not effective unless the client is receptive to the information. Readiness to learn is important. Proceeding with teaching when the client is struggling with coping is not sensitive to the client's individual needs. PTS:1DIF:ModerateREF:p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Application

All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others? 1)Thinking and reasoning about the client's care 2)Providing hands-on client care 3)Carrying out physician orders 4)Delegating to assistive personnel

ANS: 1 A substantial portion of the nursing role involves using clinical judgment, critical thinking, and problem solving, which directly affect the care the client will actually receive. Providing hands-on care is important; however, clinical judgment, critical thinking, and problem solving are essential to do it successfully. Carrying out physician orders is a small part of a nurse's role; it, too, requires nursing assessment, planning, intervention, and evaluation. Many simple nursing tasks are being delegated to nursing assistive personnel; delegation requires careful analysis of patient status and the appropriateness of support personnel to deliver care. Another way to analyze this question is that none of the options of providing hands-on care, carrying out physician orders, and delegating to assistive personnel is required for the nurse to think and reason about a client's care; so the answer must be 1. PTS:1DIFgrinifficultREF: p. 11

18. The nurse assesses a patients abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggest which postoperative complication? 1) Paralytic ileus 2) Small bowel obstruction 3) Diarrhea 4) Constipation

ANS: 1 Absent bowel sounds on the fourth postoperative day suggests paralytic ileus, a complication associated with abdominal surgery. A small bowel obstruction and diarrhea produce hyperactive bowel sounds. Constipation might be associated with hypoactive bowel sounds.

A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation? 1) Chest pain, pneumonitis, and inflammation of the mouth 2) Intestinal obstruction and numbness of the hands 3) Hypotension, oliguria, and tingling of the feet 4) Tachycardia, hematuria, and diaphoresis

ANS: 1 Acute adverse effects of mercury inhalation include chest pain, inflammation of mouth, pneumonitis, respiratory damage, wakefulness, muscle weakness, anorexia, headache, and ringing in the ears, Chronic effects include numbness or tingling of the hands, lips, and feet, and personality changes. Intestinal obstruction is an acute effect of mercury ingestion. Hypotension, oliguria, hematuria, and diaphoresis are not acute effects of mercury inhalation. PTS: 1 DIF: Difficult REF: p. 659 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

The nurse administers heparin 5000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document? 1)Injection site 2)Previous site of administration 3)Patient response to medication 4)Heart rate prior to administration

ANS: 1 After administering an injection, the nurse must document the injection site to prevent the patient from receiving repeated injections in the same location. Heparin 5000 units subQ was prescribed for the patient. The previous route of administration is already documented on the MAR from the previous dose and would not be noted in the entry for the current dose. The patient's response to medication is recorded in the nurse's narrative note in the traditional paper for the electronic health record. When the nurse signs out that the drug was given in the medication administration record, she is validating that she administered the drug according to the physician's order. Heparin does not affect heart rate.

5. A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing? 1) Yogurt 2) Pasta 3) Oatmeal 4) Broccoli

ANS: 1 Although the patient may have diarrhea, the goal is not to stop the diarrhea, but to eliminate the pathogens from the digestive tract. The active bacteria in yogurt stimulate peristalsis and promote healing of intestinal infections. Pasta is a low-fiber food that slows peristalsis. It does not promote healing of intestinal infections. Oatmeal stimulates peristalsis, but it does not promote healing of intestinal infections. Broccoli stimulates gas production; it is ineffective against intestinal infections.

20. A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated? 1) Apply an indwelling fecal drainage device. 2) Apply an external fecal collection device. 3) Place an incontinence garment on the patient. 4) Place a waterproof pad under the patients buttocks.

ANS: 1 An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive days of use; and for patients who have severe hemorrhoids, recent bowel, rectal, or anal surgery or injury; rectal or anal tumors; or stricture or stenosis. External devices are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. Even with absorbent products or an external collection device, the nurse should place a waterproof pad under the patient to protect the bed linens.

The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? 1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrain the client before inserting the urinary catheter. 4) Inform the provider that the nurse cannot perform the procedure because the client is confused.

ANS: 1 Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance. PTS:1DIF:ModerateREF:p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

Which of the following is an example of what traditional medicine and complementary and alternative medicine therapies have in common? 1)Both can produce adverse effects in some patients. 2)Both use prescription medications. 3)Both are usually reimbursed by insurance programs. 4)Both are regulated by the FDA.

ANS: 1 Both traditional and complementary therapies can produce adverse effects in some patients. Many medications are derived from herbs, but the alternative treatments usually use the herbs, not prescription medication. Insurance programs do not necessarily reimburse alternative treatments, because many are not supported by sound scientific research methodology. Alternative medications are not regulated by the FDA. PTS:1DIF:ModerateREF:p. 20

Which statement accurately describes delegation? 1) Transferring authority to another person to perform a task in a selected situation 2) Collaborating with other caregivers to make decisions and plan care 3) Scheduling treatments and activities with other departments 4) Performing a planned intervention from a critical pathway

ANS: 1 Delegation is the transfer to another person of the authority to perform a task in a selected situation—the person delegating retains accountability for the outcome of the activity. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. Coordination of care involves scheduling treatments and activities with other departments. Implementation is the process of performing planned interventions. PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Knowledge

A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of 1)The Minimum Data Set (MDS) for assessment 2)Situation-background-assessment-recommendation (SBAR) for reporting 3)Healthcare Financing Administration guidelines prior to surgery 4)Joint Commission guidelines for discharge planning

ANS: 1 Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a hand-off report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities, but only the MDS assessment is mandated by federal law.

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident of a long-term care facility? 1)14 days 2)3 days 3)2 days 4)24 hours

ANS: 1 Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility.

7. The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and: 1) Have the patient void directly into the bedpan. 2) Pour the urine into a graduated container. 3) Read the volume with the container on a flat surface at eye level. 4) Observe the color and clarity of the urine in the bedpan.

ANS: 1 First, the nurse should put on gloves and have the patient void directly into the bedpan. Next, she should pour the urine into a graduated container, place the measuring device on a flat surface, and read the amount at eye level. She should observe the urine for color, clarity, and odor. Then, if no specimen is required, she should discard the urine in the toilet and clean the container and bedpan. Finally, she should record the amount of urine voided on the patients intake and output record.

1. What is the most significant change in kidney function that occurs with aging? 1) Decreased glomerular filtration rate 2) Proliferation of micro blood vessels to renal cortex 3) Formation of urate crystals 4) Increased renal mass

ANS: 1 Glomerular filtration rate is the amount of filtrate formed by the kidneys in 1 minute. Renal blood flow progressively decreases with aging primarily because of reduced blood supply through the micro blood vessels of the kidney. A decrease in glomerular filtration is the most important functional deficit caused by aging. Urate crystals are somewhat common in the newborn period. They might indicate that the infant is dehydrated. In older people, they result from too much uric acid in the blood, although this is not related to aging. Renal mass (weight) decreases over time, starting around age 30 to 40.

Health screening activities are designed to: 1) Detect disease at an early stage. 2) Determine treatment options. 3) Assess lifestyle habits. 4) Identify healthcare beliefs.

ANS: 1 Health screening activities are designed to detect disease at an early stage so that treatment can begin before there is an opportunity for disease to spread or become debilitating. PTS: 1 DIF: Moderate REF: p. 879 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension

The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? 1) Encourage the child to continue coughing. 2) Deliver upward abdominal thrusts with a fisted hand. 3) Deliver five rapid back blows between the shoulder blades. 4) Perform a blind finger sweep of the child's mouth.

ANS: 1 If the nurse suspects aspiration in a child who is coughing vigorously, the nurse should encourage the child to continue coughing. If coughing weakens, the nurse should perform the choking maneuver by administering five rapid back blows alternated with five upward thrusts to the upper abdomen with a fisted hand, just below the rib cage. A blind finger sweep should never be performed because it could push the foreign object into the airway. PTS:1DIF:Moderate REF: ESG, Box 23-5, Rescue Maneuver for Choking: Adult or Child Over Age 12 Months KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

16. The surgeon orders hourly urine output measurement for a patient after abdominal surgery. The patients urine output has been greater than 60 mL/hour for the past 2 hours. Suddenly the patients urine output drops to almost nothing. What should the nurse do first? 1) Irrigate the catheter with 30 mL of sterile solution. 2) Replace the patients indwelling urinary catheter. 3) Infuse 500 mL of normal saline solution IV over 1 hour. 4) Notify the surgeon immediately.

ANS: 1 If the patients urinary output suddenly ceases, the nurse should irrigate the urinary catheter to assess whether the catheter is blocked. If no blockage is detected, the nurse should notify the surgeon. The surgeon may request that the catheter be changed if irrigation does not help or if the tubing is not kinked. However, the nurse should not change a catheter in the immediate postoperative period without consulting with the surgeon. The surgeon may prescribe an IV fluid bolus if the patient is suspected to have a deficient fluid volume.

Which of the following contributions of Florence Nightingale had an immediate impact on improving patients' health? 1)Providing a clean environment 2)Improving nursing education 3)Changing the delivery of care in hospitals 4)Establishing nursing as a distinct profession

ANS: 1 Improved sanitation (a clean environment) greatly and immediately reduced the rate of infection and mortality in hospitals. The other responses are all activities of Florence Nightingale that improved healthcare or nursing, but the impact is long range, not immediate. PTS: 1 DIF: Easy REF: V1, p. 3; student must infer from content | V1, p. 10; student must infer from content KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application

13. The student nurse asks the provider if she will prescribe an indwelling urinary catheter for a hospitalized patient who is incontinent. The provider explains that catheters should be utilized only when absolutely necessary because: 1) They are the leading cause of nosocomial infection. 2) They are too expensive for routine use. 3) They contain latex, increasing the risk for allergies. 4) Insertion is painful for most patients.

ANS: 1 Indwelling urinary catheters should not be routinely used for hospitalized patients with incontinence because they are the leading cause of healthcare-acquired infection (nosocomial). The cost of an indwelling urinary catheter should not deter its use if necessary. Latex-free catheters are available for patients with or at risk for latex allergy. Insertion may be somewhat uncomfortable, but it should not be painful.

Which type of client-centered evaluation is performed at specific, scheduled times? 1) Intermittent 2) Ongoing 3) Terminal 4) Process

ANS: 1 Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the client's health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation. PTS:1DIF:EasyREF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall

In the Leavell and Clark model of health protection, the chief distinction between the levels of prevention is: 1) The point in the disease process at which they occur. 2) Placement on the Wheels of Wellness. 3) The level of activity required to achieve them. 4) Placement in the Model of Change.

ANS: 1 Leavell and Clark identified three levels of activities for health protection: primary, secondary, and tertiary. Interventions are classified according to the point in the disease process in which they occur. PTS:1DIFgrinifficultREF:p. 879 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Analysis

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning)

ANS: 1 Loss of muscle strength and joint mobility place older adults at risk for falls. Choking, drowning, and ingesting poisons are primary safety concerns for infants and toddlers. PTS:1DIF:ModerateREF:p. 653 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall

A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct? 1) The virus mutates too rapidly to develop a vaccine. 2) Vaccines are developed only for very serious illnesses. 3) Researchers are focusing efforts on an HIV vaccine. 4) The virus for the common cold has not been identified.

ANS: 1 More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV infection, others continue to research the common cold. PTS:1DIF:ModerateREF:p. 616 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Nurses have the potential to be very influential in shaping healthcare policy. Which of the following factors contributes most to nurses' influence? 1)Nurses are the largest health professional group. 2)Nurses have a long history of serving the public. 3)Nurses have achieved some independence from physicians in recent years. 4)Political involvement has helped refute negative images portrayed in the media.

ANS: 1 Nurses are trusted professionals and the largest health professional group. As such, they have political power to effect changes. If nursing were a small group, there would be little potential for power in shaping policies, even if all the other answers were true. Serving the public, while positive, does not necessarily help nurses to be influential in establishing health policy. Independence from physicians, although positive, does not necessarily make nurses influential in establishing healthcare policy. Refuting negative media, although positive, does not necessarily make nurses influential in establishing healthcare policy. PTS: 1 DIF: Moderate REF: p. 21

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? 1)"Occurrence reports track problems and identify areas for quality improvement." 2)"Occurrence reports are required by the Food and Drug Administration to report drug errors." 3)"The Joint Commission requires occurrence reports for all client falls." 4)"Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

ANS: 1 Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or Joint Commission.

Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown

ANS: 1 Scrupulous hand washing is the most important part of medical asepsis. Donning gloves, applying sterile drapes before procedures, and wearing a protective gown may be needed to ensure asepsis, but they are not the most important aspect because microbes causing most healthcare-related infections are transmitted by lack of or ineffective hand washing. PTS: 1 DIF: Easy REF: p. 617 KEY: Nursing process: Interventions | Client need: Safe Care Environment | Cognitive level: Comprehension

Which individuals should receive annual lipid screening? 1) All overweight children 2) All adults 20 years and older 3) Persons with total cholesterol greater than 150 mg/dL 4) Persons with HDL less than 40 mg/dL

ANS: 1 The American Academy of Pediatrics takes a targeted approach, recommending that overweight children receive cholesterol screening, regardless of family history or other risk factors for cardiovascular disease. The American Heart Association recommends that all adults age 20 years or older have a fasting lipid panel at least once every 5 years. If total cholesterol is 200 mg/dL or greater—or HDL is less than 40 mg/dL—frequent monitoring is required. PTS: 1 DIF: Moderate REF: p. 888; Box 27-1 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

The Joint Commission's national Speak Up® campaign encourages patients to become active and informed participants on the healthcare team. The goal is to: 1) prevent healthcare errors. 2) help control the cost of healthcare. 3) reduce the number of automobile accidents. 4) provide a forum for people without health insurance

ANS: 1 The Joint Commission, with the Centers for Medicare and Medicaid Services, urges patients to take a role in preventing healthcare errors by becoming active, involved, and informed participants on the healthcare team. A reduction in healthcare errors could indirectly reduce healthcare costs, but this is not the intent of the campaign. The campaign has nothing to do with automobile accidents, as might be deduced from the fact that the Joint Commission and Medicare/Medicaid regulate healthcare agencies. The campaign has little relationship to insurance, other than to encourage clients to speak up, ask questions, and know their rights. PTS:1DIFgrinifficultREF:p. 664 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension

Which task can be delegated to nursing assistive personnel (NAP)? 1) Turn and reposition the client every 2 hours. 2) Assess the client's skin condition. 3) Change pressure ulcer dressings every shift. 4) Apply hydrocolloid dressing to the pressure ulcer.

ANS: 1 The nurse can delegate turning the client every 2 hours to the NAP. Assessing the client's skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment. PTS:1DIF:ModerateREF:pp. 122-124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

16. A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother? 1) Consume a diet consisting of bananas, white rice, applesauce, and toast. 2) Drink large quantities of water regularly to prevent dehydration. 3) Take loperamide (an antidiarrheal) as needed to control diarrhea. 4) Increase the consumption of raw fruits and vegetables.

ANS: 1 The nurse should encourage the patient with diarrhea who has an appetite to consume a diet that consists of bananas, white rice, applesauce, and toast. These foods are easy to digest, provide calories for energy, and help provide a source of calcium. The patient should sip liquids frequently to prevent dehydration; large quantities might worsen diarrhea. Medication, such as loperamide (Imodium), is usually reserved for chronic diarrhea. Raw fruits and vegetables may worsen diarrhea.

18. A mother tells the nurse at an annual well-child checkup that her 6-year-old son occasionally wets himself. Which response by the nurse is appropriate? 1) Explain that occasional wetting is normal in children of this age. 2) Tell the mother to restrict her childs activities to avoid wetting. 3) Suggest time out to reinforce the importance of staying dry. 4) Inform the mother that medication is commonly used to control wetting

ANS: 1 The nurse should explain that occasional wetting is normal in children during the early school years. The mother should handle the situation calmly and avoid punishing the child. Medications are occasionally prescribed for nocturnal enuresis when the child is older and not sleeping at home, but not for occasional daytime wetting.

12. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, For 3 days prior to testing, I should avoid eating: 1) Beef. 2) Milk. 3) Eggs. 4) Oatmeal.

ANS: 1 The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and certain raw fruits and vegetables for 3 days prior to fecal occult blood testing.

20. Which action should the nurse take when beginning bladder training using scheduled voiding? 1) Offer the patient a bedpan every 2 hours while she is awake. 2) Increase the voiding interval by 30 to 60 minutes each week. 3) Frequently ask the patient if she has the urge to void. 4) Increase the frequency between voiding even if urine leakage occurs.

ANS: 1 The nurse should offer the patient the bedpan or assist the patient to the bathroom every 2 hours while she is awake. You would encourage the patient to get up once during the night to void, but awakening the patient every 2 hours would lead to fatigue. If the patient adheres to the schedule, the voiding interval should be increased by 15 to 30 minutes each week. Simply asking the patient about the urge to void does not help to manage bladder emptying.

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? 1)Repeat the order to the prescriber even if she believes she understood the order correctly. 2)Immediately notify the pharmacy of the order and verify it with a pharmacist. 3)Ask the unit secretary to listen to the prescriber on the phone to verify the order. 4)Transcribe the order onto note paper and verify the dosage in a drug handbook.

ANS: 1 The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unit secretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the order directly on the patient's chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error.

A nurse is teaching a group of mothers about first aid. Should poison come in contact with their child's clothing and skin, which action should the nurse instruct the mothers to take first? 1) Remove the contaminated clothing immediately. 2) Flood the contaminated area with lukewarm water. 3) Wash the contaminated area with soap and water and rinse. 4) Call the nearest poison control center immediately.

ANS: 1 The nurse should tell the mother to first remove the contaminated clothing as quickly as possible. Then, flood the contaminated area with lukewarm water. Next, gently wash the area with soap and water and rinse. Have someone call the poison control center. It does not need to be a local poison control center. Additionally, it is most important to remove contact between the skin and poison before doing anything. PTS: 1 DIF: Moderate REF: ESG, Chapter 23, Box 23-2, "Home Care: If Poisoning Occurs at Home" KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

The patient's medical record contains the following documentation: 06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN Which type of charting has the nurse used? 1)Narrative 2)Focus 3)SOAP 4)PIE

ANS: 1 The nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patient's concerns, problems, and strengths in a three-column format. SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems.

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? 1) Nurse who delegated the task 2) Licensed practical nurse working with the NAP 3) Unit nurse manager 4) Charge nurse for the shift

ANS: 1 The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions and provide help, if necessary. PTS:1DIF:EasyREF: p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Recall

Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare? 1)Social worker 2)Occupational therapist 3)Physician's assistant 4)Technologist

ANS: 1 The social worker coordinates services and counsels patients about financial, housing, marital, and family issues affecting healthcare. The occupational therapist helps patients regain function and independence for activities of daily living. Physician's assistants work under the physician's direction to diagnose certain diseases and injuries. Technologists provide a variety of specific functions in hospitals, diagnostic centers, and emergency care. For example, laboratory technologists aid in the diagnosis and treatment of patients by examining blood, urine, tissue, and body fluids. Radiology technologists perform x-rays and other diagnostic testing. PTS:1DIF:ModerateREF:ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "What Healthcare Providers Will You Work With?"

A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. This intervention is most likely being directed by a 1)Critical pathway 2)Nursing care plan 3)Case manager 4)Traditional care model

ANS: 1 This patient's care is most likely being directed by a critical pathway. A critical pathway is a multidisciplinary approach to care that sequences interventions over a length of stay for a given case type, such as total abdominal hysterectomy. Using this model, the patient can be assisted out of bed as soon as her vital signs are stable. Using the traditional model, the nurse would have to obtain a physician's order to assist the patient out of bed after surgery. The nursing care plan guides nursing care but cannot specify when the patient can get out of bed postoperatively without a physician's order. When case management is used, care is coordinated by the case manager across the healthcare setting, but the case manager does not direct each care intervention. PTS:1DIF:ModerateREF:ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "Issues Related to Healthcare Reform"

A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? 1) Endogenous nosocomial 2) Exogenous nosocomial 3) Latent 4) Primary

ANS: 1 Thrush in this patient is an example of an endogenous nosocomial infection. This type of infection arises from suppression of the patient's normal floras as a result of some form of treatment, such as antibiotics. Normal floras usually keep yeast from growing in the mouth. In exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent infection causes no symptoms for long periods. An example of a latent infection is human immunodeficiency virus infection. A primary infection is the first infection that occurs in a patient. PTS: 1 DIF: Difficult REF: p. 608 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

14. Which action should the nurse take to assess a 2-year-old child for pinworms? 1) Press clear cellophane tape against the anal opening at night to obtain a specimen. 2) Collect a freshly passed stool from a diaper using a wooden specimen blade. 3) Place a smear of stool on a slide and add two drops of reagent. 4) Prepare the patient for a flat plate (x-ray) of the abdomen.

ANS: 1 To assess for pinworms, the nurse should press cellophane tape against the childs anal opening during the night or as soon as he awakens. Remove the tape immediately, and place it on a slide. Perineal swabs may also be necessary for microscopic study. Collecting a fresh stool specimen from a diaper describes the method for an infant or toddler. Placing a smear of stool on a slide and adding a reagent describes fecal occult blood testing. An abdominal flat plate is not a method of assessing for pinworms.

The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1) Closing the patient's door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterile field 4) Remaining 6 inches away from the sterile field during the procedure

ANS: 1 To maintain sterile technique, the nurse should close the patient's door and limit the number of persons entering and exiting the room because air currents can carry dust and microorganisms. Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between people and the sterile field to prevent contamination. PTS: 1 DIF: Moderate REF: p. 629 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

5. The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? 1) Skin breakdown 2) Urinary tract infection 3) Bowel incontinence 4) Renal calculi

ANS: 1 Urine contains ammonia, which may cause excoriation with prolonged contact with the skin. Bowel incontinence, not urinary incontinence, increases the patients risk for urinary tract infection. Immobility and high consumption of calcium-containing foods increase the risk for renal calculi.

Which action by the nurse breaches patient confidentiality? Select all that apply. 1)Leaving patient data displayed on a computer screen where others may view it 2)Remaining logged on to the computer system after documenting patient care 3)Faxing a patient report to the nurses' station where the patient is being transferred 4) Informing the nurse manager of a change in the patient's condition

ANS: 1, 2 Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use. Faxing a report to the nurses' station receiving a patient does not breach patient confidentiality because it is located at the nurses' station out of others' view. Anyone directly involved in the patient's care has the right to know about the patient's condition without breaching patient confidentiality.

1. Which factor(s) place(s) the patient at risk for constipation? Choose all that apply. 1) Sedentary lifestyle 2) High-dose calcium therapy 3) Lactose intolerance 4) Consuming spicy foods

ANS: 1, 2 Physical activity stimulates peristalsis and bowel elimination. Therefore, those with a sedentary lifestyle commonly experience constipation. High-dose calcium therapy also predisposes a patient to constipation. Lactose intolerance and consuming spicy foods are associated with a nursing diagnosis of Diarrhea, not Constipation.

Which statement by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. 1)"I can wait until the end of the shift to document my care." 2)"Charting every 2 hours is the most appropriate way to document nursing care." 3)"I find it easier to chart before I go to lunch and then after my shift report." 4)"I should chart as soon as possible after nursing care is given."

ANS: 1, 2, 3 Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or reporting after the shift is over is too long of a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report.

In performing a hand-off report, the nurse should communicate information on which of the following? Select all that apply. 1)Teaching performed 2)Any change in client status 3)Treatments administered 4)Hygiene measures performed

ANS: 1, 2, 3 Hand-off reports include any client teaching done, therapies and treatments administered, and changes in the client's status. Hygiene care is routinely done in inpatient settings and is usually recorded on a flow sheet. Hand-off reports should be succinct and not contain routine information.

The nurse working in an ambulatory care program asks questions about the client's locus of control as a part of his assessment because of which of the following? Choose all that apply. 1) People who feel in charge of their own health are the easiest to motivate toward change. 2) People who feel powerless about preventing illness are least likely to engage in health promotion activities. 3) People who respond to direction from respected authorities often prefer a health promotion program supervised by a health provider. 4) People who feel in charge of their own health are less motivated by health promotion activities.

ANS: 1, 2, 3 Identifying a person's locus of control helps the nurse determine how to approach a client about health promotion. People who feel powerless about preventing illness are least likely to engage in health promotion activities. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider. Clients who feel in charge of their own health are the easiest to motivate toward positive change. PTS:1DIFgrinifficultREF:p. 888 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Comprehension

Which of the following actions demonstrate how nurses promote health? Select all that apply. 1) Role modeling 2) Educating patients and families 3) Counseling 4) Providing support

ANS: 1, 2, 3, 4 Nurses promote health by acting as role models, counseling, providing health education, and providing and facilitating support. PTS:1DIF:EasyREF:pp. 891-892 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

The nurse is implementing a wellness program based on data gathered from a group of low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Choose all that apply. 1) Creating a weekly discussion group focused on contemporary news 2) Facilitating a relationship between local pastors and residents of subsidized housing 3) Coordinating a senior tutorial program for local children at the housing center 4) Establishing an on-site healthcare clinic operating one day per week

ANS: 1, 2, 3, 4 The Wheels of Wellness model identifies the following dimensions of health: emotional, intellectual, physical, spiritual, social/family, and occupational. A weekly discussion group stimulates intellectual health. A relationship between local pastors and those living in subsidized housing creates a climate for spiritual health. A tutorial program offered by seniors to local children will facilitate occupational health. An on-site healthcare clinic addresses physical health. PTS:1DIFgrinifficultREF:p. 881 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Analysis

The nurse who understands the electronic health record (EHR) can do which of the following? Select all that apply. 1)Facilitate evidence-based nursing practice 2)Promote efficient use of the nurse's documentation time 3)Reduce the opportunity for interdisciplinary collaboration 4)Ensure improved client safety and outcomes

ANS: 1, 2, 4 Electronic health records (EHR) have many advantages, including the facilitation of evidence-based nursing practice, efficient use of the nurse's documentation time, and improved client safety and outcomes. The EHR does not impair interdisciplinary collaboration; rather, the EHR fosters communication and collaboration among healthcare team members.

Health promotion programs assist a person to advance toward optimal health. Which of the following activities might such programs include? Choose all that apply. 1) Disseminating information 2) Changing lifestyle and behavior 3) Prescribing medications to treat underlying disorders 4) Environmental control programs

ANS: 1, 2, 4 Health promotion programs may be categorized into four types: disseminating information, programs for changing lifestyle and behavior, environmental control programs, and wellness appraisal and health risk assessment programs. Prescribing medications to treat underlying disorders is an activity that fosters health focused at an individual level rather than at a group program level. PTS:1DIF:ModerateREF:p. 881 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Recall

Goals for Healthy People 2020 include which of the following? Choose all that apply. 1) Eliminate health disparities among various groups. 2) Decrease the cost of healthcare related to tobacco use. 3) Increase the quality and years of healthy life. 4) Decrease the number of inpatient days annually.

ANS: 1, 3 The four overarching goals of Healthy People 2020 are to (1) increase the quality and years of healthy life, free of disease, injury, and premature death; (2) eliminate health disparities and improve health for all groups of people; (3) create physical and social environments for people to live a healthy life; and (4) promote healthy development for people in all stages of life. PTS: 1 DIF: Moderate REF: p. 890 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Recall

The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. The nurse will know that the teaching was effective if the NAP demonstrate what? Select all that apply. The NAP: 1) uses a paper towel to turn off the faucet. 2) holds fingertips above the wrists while rinsing off the soap. 3) removes all rings and watch before washing hands. 4) cleans underneath each fingernail.

ANS: 1, 3, 4 Hand washing requires at least 15 seconds of washing, which includes lathering all surfaces of the hands and fingers to be effective. The fingers should be held lower than the wrists. PTS: 1 DIF: Moderate REF: pp. 633-634 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall

Which of the following protect(s) the body against infection? Select all that apply. 1) Eating a healthy, well-balanced diet 2) Being an older adult or an infant 3) Leisure activities three times a week 4) Exercising for 30 minutes 5 days a week

ANS: 1, 3, 4 Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and various lifestyle factors can make the body more susceptible to infection. PTS:1DIF:EasyREF:pp. 612, 616 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall

According to Pender's health promotion model, which variables must be considered when planning a health promotion program for a client? Choose all that apply. 1) Individual characteristics and experiences 2) Levels of prevention 3) Behavioral outcomes 4) Behavior-specific cognition and affect

ANS: 1, 3, 4 Pender identified three variables that affect health promotion: individual characteristics and experiences, behavior-specific cognition and affect, and behavioral outcomes. Levels of prevention were identified by Leavell and Clark; three levels relate to health protection. The levels differ based on their timing in the illness cycle. PTS: 1 DIF: Difficult REF: pp. 880-881 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension

The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply. 1) 75-year-old patient newly admitted to the hospital with dehydration 2) 65-year-old patient hospitalized for a stroke, whose blood pressure is 188/90 mm Hg 3) 92-year-old patient with stable vital signs who was admitted with a urinary tract infection 4) 56-year-old patient with chronic renal failure who has vital signs within his normal range

ANS: 1, 3, 4 The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse. PTS: 1 DIF: Difficult REF: pp. 122-124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

Which of the following are examples of a health-promotion activity? Select all that apply. 1)Helping a client develop a plan for a low-fat, low-cholesterol diet 2)Disinfecting an abraded knee after a child falls off a bicycle 3)Administering a tetanus vaccination after an injury from a car accident 4)Distributing educational brochures about the benefits of exercise

ANS: 1, 4 Health promotion includes strategies that promote positive lifestyle changes. Disinfecting an abraded knee is a treatment/intervention for an injury. Administering a vaccination is a disease-prevention and treatment activity. PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in text KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Application

Which statement by the student nurse indicates an understanding of the nursing Kardex®? Choose all correct answers. 1)"The Kardex® pulls data from multiple areas of the patient's chart." 2)"The Kardex® is usually kept at the patient's bedside." 3)"The Kardex® is used to document patient response to interventions." 4)"The Kardex® summarizes the plan of care and guides nursing care."

ANS: 1, 4 The Kardex® is a tool that pulls data from multiple areas of the patient's health record and helps guide nursing care. Responses to interventions are documented on flow sheets and in nurses' notes. Kardexes® are paper forms that are kept together in a portable file at the nurses' station to allow all team members access to the summary information. The file is portable, so it could be carried to the bedside briefly; however, it is not stored there, as a general rule.

During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such a spill. Select all that are appropriate. How should the nurse intervene? 1) Using gloves and a paper towel, place the mercury in a plastic bag, and dispose of it. 2) Notify the hazardous material management team immediately. 3) Evacuate the area immediately. 4) After putting on a gown, gloves, and a mask, clean up the mercury. 5) Wash her hands well after removing the spill. 6) Ventilate the area well for several days.

ANS: 1, 5, 6 The nurse should put on gloves and use a paper towel to pick up the mercury. Then place the mercury, broken thermometer, and soiled paper towel into a plastic bag along with the gloves. Next, the nurse should dispose of the plastic bag, wash her hands, and ventilate the area well. It is not necessary to notify the hazardous material management team or evacuate the area for a spill this small, unless agency policy actually mandates that. The nurse does not need to put on a gown and mask to dispose of the mercury. PTS: 1 DIF: Moderate REF: pp. 674-675 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A patient refuses a dose of medication. How should the nurse document the event? 1)Patient is uncooperative and refuses the prescribed dose of digoxin. 2)Patient refuses the 0900 dose of digoxin. 3)Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. 4)0900 dose of digoxin not given.

ANS: 2 "Patient refuses the 0900 dose of digoxin" objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. "0900 dose of digoxin not given" provides no explanation as to why the medication was not given. The other two options offer judgmental information, which should be avoided when charting.

Which of the following is a client outcome criterion? 1) Central venous catheter site infection does not occur (90% of cases). 2) Client will sit out of bed in a chair for 20 minutes three times per day. 3) Postoperative phlebitis does not occur (95% of cases). 4) Falls will decrease by 2% between January 1 and March 30.

ANS: 2 A client outcome criterion states the client health status or behaviors one wishes to effect. "Client will sit out of bed . . ." is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution. PTS:1DIF:ModerateREF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

Which of the following is the most valid criterion for determining the status of a patient's anxiety at discharge? The patient 1) Has a relaxed facial expression 2) States that he feels more relaxed today 3) Shows no physiological signs of anxiety (e.g., pallor) 4) Has no further questions about home care

ANS: 2 A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety. PTS: 1 DIF: Difficult REF: p. 127 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application

4. Which medication class will the primary care provider most likely prescribe to increase urine output in the patient admitted with congestive heart failure? 1) Thiazide diuretic 2) Loop diuretic 3) MAO inhibitor 4) Anticholinergic

ANS: 2 A loop diuretic [e.g., Furosemide (Lasix)] increases urine elimination. It works by limiting the reabsorption of water in the renal tubules and is used to reduce congestion in the cardiopulmonary circulation. A thiazide diuretic is used to treat high blood pressure by reducing the amount of sodium and water in the blood vessels. An MAO inhibitor [e.g., phenelzine (Nardil)] is an antidepressant that is used after other medications have proven unsuccessful in lifting symptoms of serious depression. Anticholinergics [e.g., ipratropium (Atrovent)] relax smooth muscle in the airways. Also known as antispasmodics, they reduce airway constriction experienced by those with asthma, for example.

22. Which daily urine output is within normal limits for a newborn weighing 8 pounds? 1) 288 mL 2) 180 mL 3) 36 mL 4) 18 mL

ANS: 2 A newborn weighing 8 pounds (3.6 kg) should produce 15 to 60 mL of urine per kilogram per day. If the newborn produces 50 mL/kg/day and weighs 3.6 kg, he will produce a total of 180 mL in 24 hours. The other options are not within normal limits and require further assessment.

An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she be transferred? 1)Nursing home 2)Rehabilitation center 3)Outpatient therapy center 4)None of these; she should receive home healthcare

ANS: 2 A skilled nursing facility primarily provides skilled nursing care for patients who can be expected to improve with treatment. For example, a patient who no longer needs hospitalization may transfer to a skilled nursing facility to get skilled care until she is able to return home. A nursing home provides custodial care for people, like this patient, who cannot live on their own but who are not sick enough to require hospitalization. It provides a room, custodial care, and opportunity for recreation. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate. PTS:1DIF:ModerateREF:p. 18 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

As a general rule, how much liquid soap should the nurse use for effective hand washing? At least: 1) 2 mL 2) 3 mL 3) 6 mL 4) 7 mL

ANS: 2 APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing. PTS:1DIF:EasyREF:p. 633 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

Of the following, the biggest disadvantage of having nursing assistive personnel (NAP) help nurses is that the nurse 1)Must know what aspects of care can legally and safely be delegated to the NAP 2)May rely too heavily on information gathered by the NAP when making patient care decisions 3)Is removed from many components of direct patient care that have been delegated to the NAP 4)Still maintains responsibility for the patient care given by the NAP

ANS: 2 All of the options may be disadvantages to using NAPs, but making decisions based on another's information is the greatest drawback because of the potential for negatively affecting patient care. Treatment decisions based on incorrect information may cause harm to the patient. PTS:1DIFgrinifficultREF:p. 20-21; students must conclude from content

2. Considering normal developmental and physical maturation in children, for which age would a goal of Achieves bowel control by the end of this month be most realistic? 1) 18 months 2) 3 years 3) 4 years 4) 5 years

ANS: 2 Between ages 2 and 3 years, a child can typically control defecation, thereby making toilet training possible. Nevertheless, some children, especially boys, may not achieve consistent bowel control until somewhat later.

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. 1)Patient found on floor in pain after falling out of bed. 2)Patient found on floor after falling out of bed; found by NAP Smith. 3)Patient fell out of bed but is currently in bed. 4)Patient reminded to not climb OOB after falling.

ANS: 2 Charting must be accurate and succinct. Only chart what you observe. Do not chart what others have observed as your own observation. Avoid judging patients; instead, chart objectively.

The American Red Cross was established by 1)Louisa May Alcott 2)Clara Barton 3)Dorothea Dix 4)Harriet Tubman

ANS: 2 Clara Barton was an American teacher, nurse, and humanitarian who organized the American Red Cross after the Civil War. Louisa May Alcott was an American novelist who wrote Little Women in 1868. Dorothea Dix was an American activist who acted on behalf of the indigent population with mental illness. She was credited for establishing the first psychiatric institution. Harriet Tubman was an African American abolitionist and Union spy during the Civil War. After escaping captivity, she set up a network of antislavery activists, known as the Underground Railroad. PTS:1DIF:EasyREF:p. 10

The nurse works with the respiratory therapist to administer a patient's breathing treatments. He reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of 1) Delegation 2) Collaboration 3) Coordination of care 4) Supervision of care

ANS: 2 Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain the "big picture." Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity or task. PTS:1DIF:ModerateREF: pp. 122 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

he nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? 1)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain. Kay Andrews, RN 2)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN 3)09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain V.O.: Dr. D. Kelly/Kay Andrews, RN 4)09/02/13 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

ANS: 2 Correct documentation of a telephone order is as follows: "09/02/13 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.: Dr. D. Kelly/Kay Andrews, RN" (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber's name and title, nurse's name and title.) The other options demonstrate incomplete documentation of a telephone order.

A patient who has a temperature of 101°F (38.3°C) most likely requires: 1) acetaminophen (Tylenol). 2) increased fluids. 3) bedrest. 4) tepid bath.

ANS: 2 Fever, a common defense against infection, increases water loss; therefore, additional fluid is needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low-grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily bedrest, is necessary with a fever. PTS:1DIF:ModerateREF:p. 616 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

21. A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug? 1) Hypocalcemia 2) Hypokalemia 3) Hypomagnesemia 4) Hypophosphatemia

ANS: 2 Furosemide is a loop diuretic, which causes potassium to pass into the urine. This drug increases the risk for hypokalemia (low potassium); it does not cause hypocalcemia (low calcium in the blood), hypomagnesemia (low blood magnesium), or hypophosphatemia (low blood phosphorous).

Which is one of the greatest concerns with heavy and chronic use of alcohol in teens and young adults? 1) Liver damage 2) Unintentional death 3) Tobacco use 4) Obesity

ANS: 2 Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries and intentional death (suicide and homicide). Although alcohol as a depressant slows metabolism, chronic alcohol use is more likely associated with poor nutrition, which may or may not lead to obesity. Chronic alcohol use causes damage to liver cells over time in the later years. Alcohol intake is often associated with tobacco and recreational drug use; however, the risk of unintentional injury, such as car accident, suicide, or violence, is more concerning than smoking. PTS:1DIF:EasyREF:p. 879 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension

A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next? 1) Perform the Get Up and Go Test. 2) Ask the patient if he has fallen in the past year. 3) Refer the patient for a comprehensive fall evaluation. 4) Administer the Timed Up and Go Test.

ANS: 2 If a patient's gait or balance is unsteady, the nurse should question the patient for a history of falls. If the patient reports a single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteady with it, the nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds wile standing in place; stand with eyes closed while the nurse pushes gently on the sternum; walk, stop, turn around, return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform the Timed Up and Go Test; it is recommended annually for patients 65 years or older. PTS:1DIFgrinifficultREF:p. 661 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application

What type of immunity is provided by intravenous (IV) administration of immunoglobulin G? 1) Cell-mediated 2) Passive 3) Humoral 4) Active

ANS: 2 Intravenous administration of immunoglobulin G provides the patient with passive immunity. Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive immunity occurs when antibodies are transferred from an immune host, such as from a placenta to a fetus. Passive immunity is short lived. Active immunity is longer lived and comes from the host. Humoral immunity occurs by secreted antibodies binding to antigens. Cell-mediated immunity does not involve antibodies but rather is a fight of infection from macrophages that kill pathogens. PTS:1DIF:ModerateREF:ESG, Chapter 22, Supplemental Materials, Humoral Immunity KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall

Which statement pertaining to Benner's practice model for clinical competence is true? 1)Progression through the stages is constant, with most nurses reaching the proficient stage. 2)Progression through the stages involves continual development of thinking and technical skills. 3)The nurse must have experience in many areas before being considered an expert. 4)The nurse's progress through the stages is determined by years of experience and skills.

ANS: 2 Movement through the stages is not constant. Benner's model is based on integration of knowledge, technical skill, and intuition in the development of clinical wisdom. The model does not mention experience in many areas. The model does not mention years of experience. PTS:1DIF:ModerateREF:p. 15

he surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse 1)Performs oral care 2)Assists the patient out of bed 3)Assists the patient with bathing 4)Changes the patient's operative dressings

ANS: 2 OOB is the abbreviation for "out of bed." The nurse is following the physician's order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or change the patient's postoperative dressings.

What is the purpose of completing an occurrence report? 1)Provide a legal defense should the patient seek legal action after an unusual occurrence 2)Track problems and identify areas for quality improvement 3)Report errors to the Food and Drug Administration 4)Report medical errors to the Joint Commission

ANS: 2 Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal defense should a patient seek legal action or to report errors to the FDA or Joint Commission.

9. The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice, and bananas

ANS: 2 Oranges, raisins, and strawberries are high in fiber. White bread, pasta, and white rice are carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orange juice, and bananas are sources of potassium.

Which is the most commonly reported incident in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4) Treatment delays

ANS: 2 Patient falls are by far the most common incident reported in hospitals and long-term care facilities. Although equipment (e.g., infusion pump) malfunctions, missed or incorrectly identified laboratory specimen collection, and treatment delays sometimes occur, they do not occur as frequently as patient falls. PTS:1DIF:EasyREF:p. 657 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension

How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patient's room. 2) Place the tray in a special isolation bag held by a second healthcare worker at the patient's door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal. 4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.

ANS: 2 Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its contents inside a special isolation bag that is held by a second healthcare worker at the patient's door. The items must be placed on the inside of the bag without touching the outside of the bag. PTS:1DIF:ModerateREF:p. 625 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Which of the following is considered a primary care service? 1)Providing wound care 2)Administering childhood immunizations 3)Providing drug rehabilitation 4)Outpatient hernia repair

ANS: 2 Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service. Providing wound care and drug rehabilitation are examples of tertiary care services. Outpatient hernia repair surgery is an example of a secondary care service. PTS:1DIF:ModerateREF:ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "Categories of Healthcare?"

A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient? 1) Contact 2) Protective 3) Droplet 4) Airborne

ANS: 2 Protective isolation is used to protect those patients who are unusually vulnerable to organisms brought in by healthcare workers. Such patients include those with low white blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care units and labor and delivery suites, also use forms of protective isolation. PTS:1DIF:ModerateREF:p. 625 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? 1) Psychomotor 2) Interpersonal 3) Cognitive 4) Critical thinking

ANS: 2 Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills. PTS:1DIF:ModerateREF: p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Comprehension

A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? 1) Invincibility 2) Hardiness 3) Baseline strength 4) Vulnerability

ANS: 2 Research has also demonstrated that in the face of difficult life events, some people develop hardiness rather than vulnerability. Hardiness is a quality in which an individual experiences high levels of stress yet does not fall ill. There are three general characteristics of the hardy person: control (belief in the ability to control the experience), commitment (feeling deeply involved in the activity producing stress), and challenge (the ability to view the change as a challenge to grow). These traits are associated with a strong resistance to negative feelings that occur under adverse circumstances. PTS:1DIF:ModerateREF:p. 887 KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Application

2. While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patients bladder. Which statement by the instructor is best? You should: 1) Try to palpate it again; it takes practice but you will locate it. 2) Palpate the patients bladder only when it is distended by urine. 3) Document this abnormal finding on the patients chart. 4) Immediately notify the nurse assigned to the care of your patient.

ANS: 2 The bladder is not palpable unless it is distended by urine. It is not difficult to palpate the bladder when distended. The nurse should document her finding, but it is not an abnormal finding. It is not necessary to notify the nurse assigned to the patient.

Which of the following best explains why it is difficult for the profession to develop a definition of nursing? 1)There are too many different and conflicting images of nurses. 2)There are constant changes in healthcare and the activities of nurses. 3)There is disagreement among the different nursing organizations. 4)There are different education pathways and levels of practice.

ANS: 2 The conflicting images of nursing make it more important to develop a definition; they may also make it more difficult, but not to the extent that constant change does. Healthcare is constantly changing and with it come changes in where, how, and what nursing care is delivered. Constant changes make it difficult to develop a definition. Although different nursing organizations have different definitions, they are similar in most ways. The different education pathways affect entry into practice, not the definition of nursing. PTS: 1 DIF: Moderate REF: p. 11; "How Is Nursing Defined?"

The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering

ANS: 2 The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or face shield, and finally, the hair covering. PTS:1DIF:ModerateREF:pp. 637-638 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? 1) Continue using the gloves inside the package because the package is intact. 2) Remove gloves from the sterile field and use a new pair of sterile gloves. 3) Throw all supplies away that were to be used and begin again. 4) Use the gloves and make sure the yellow edges of the package do not touch the client.

ANS: 2 The gloves should be discarded because the gloves are likely to be contaminated from an outside source. The supplies do not have to be thrown away because they have not been contaminated. PTS:1DIF:ModerateREF:pp. 629, 646 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

11. Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit for invasive bladder cancer? 1) Patient will resume his normal urination pattern by (target date). 2) Patient will perform urostomy self-care by (target date). 3) Patient will perform self-catheterization by (target date). 4) Patients urine will remain clear with sufficient volume.

ANS: 2 The most appropriate outcome for this patient is the patient will perform urostomy self-care by a specific date. The patient with an ileal conduit is unable to resume a normal urination pattern; urine, along with mucus, drains continuously from the stoma site, so the urine will not be clear. Also, the phrase sufficient volume is too vague for an outcome statement. The patient with a continent urostomy inserts a catheter into the stoma to drain urine.

1. When changing a diaper, the nurse observes that a 2-day-old infant has passed a green-black, tarry stool. What should the nurse do? 1) Notify the provider immediately. 2) Do nothing; this is normal. 3) Give the baby sterile water until the mothers milk comes in. 4) Apply a skin barrier cream to the buttocks to prevent irritation.

ANS: 2 The nurse should do nothing; this is normal. During the first few days of life, a term newborn passes green-black, tarry stools known as meconium. Stools transition to a yellow-green color over the next few days. After that, the appearance of stools depends upon the feedings the newborn receives. Sterile water does nothing to alter this progression. Meconium stools are more irritating to the buttocks than other stools because they are so sticky and the skin usually must be rubbed to cleanse it. However, meconium leads to skin breakdown like a watery stool does.

14. A patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure? 1) I will need to replace the catheter weekly. 2) I can use clean, rather than sterile, technique at home. 3) I will remember to inflate the catheter balloon after insertion. 4) I will dispose of the catheter after use and get a new one each time.

ANS: 2 The nurse should inform the patient that clean technique can be used after discharge. The patient should wash his hands before the procedure, then wash the reusable catheter in soap and water, and rinse and store it in a clean, dry place. It is not necessary for the patient to use a new catheter for each catheterization. The patient should use a straight catheter; therefore, a balloon is not inflated after insertion. Straight catheters are removed immediately after use.

15. The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowlers position 2) Left side-lying position 3) Supine with the head of the bed lowered flat 4) Supine with the head of bed raised to 30 degrees

ANS: 2 The nurse should position an immobile patient in a left side-lying position to irrigate his colostomy. Semi-Fowlers, supine with the bed lowered flat, and the supine position with the head of bed elevated to 30 are not appropriate positions for colostomy irrigation.

A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first? 1) Apply a cloth vest restraint. 2) Encourage a family member to stay with the patient. 3) Administer lorazepam (an antianxiety medication). 4) Keep the patient's bed side rails up.

ANS: 2 The nurse should use one-to-one supervision with this patient to maintain the patient's safety. One way to accomplish this is by encouraging a family member to stay with the patient. Restraints should be used only when all other less-restrictive measures have failed and are absolutely necessary to prevent injury to the patient. Restraints have been shown to jeopardize patient safety. It is not appropriate to administer sedation for the purpose of keeping the patient in bed; this is a form of restraint. Keeping the side rails up is also a form of restraint and increases the risk for falling. PTS: 1 DIF: Moderate REF: p. 673 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? 1) Droplet transmission 2) Airborne transmission 3) Direct contact 4) Indirect contact

ANS: 2 The organisms responsible for measles and tuberculosis, as well as many fungal infections, are spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect contact or droplet transmission. PTS:1DIF:ModerateREF:p. 608 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

11. The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis? 1) Prepare the patient for an abdominal flat plate. 2) Collect a stool specimen that contains 20 to 30 mL of liquid stool. 3) Administer a laxative to prepare the patient for a colonoscopy. 4) Test the patients stool using a fecal occult test.

ANS: 2 To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that contains 20 to 30 mL of liquid stool. An abdominal flat plate and a fecal occult blood test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis.

8. The nurse instructs a woman about providing a clean-catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure? 1) I will be sure to urinate into the hat you placed on the toilet seat. 2) I will wipe my genital area from front to back before I collect the specimen midstream. 3) I will need to lie still while you put in a urinary catheter to obtain the specimen. 4) I will collect my urine each time I urinate for the next 24 hours.

ANS: 2 To obtain a clean-catch urine specimen, the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream. This follows the principle of going from clean to dirty. The nurse should have the ambulatory patient void into a hat (container for collecting the urine of an ambulatory patient) when monitoring urinary output, but not when obtaining a clean-catch urine specimen. A urinary catheter is required for a sterile urine specimen, not a clean-catch specimen. A 24-hour urine collection may be necessary to evaluate some disorders, but a clean-catch specimen is a one-time collection.

A resident in a long-term care facility receiving Medicare funds requires care for a stage 2 pressure ulcer. How often must the nurse document this patient's care? 1)Every 2 weeks 2)Every shift 3)Every week 4)Every 3 months

ANS: 2 When a patient requires Medicare-reimbursed services, such as wound care, documentation is required every shift. Those who require assistance with medications, nutrition, and activities of daily living must have a summary written by a registered nurse or licensed practical nurse every 2 weeks. A summary must also be recorded on a weekly basis for those who require wound care. The Minimum Data Set must be updated every 3 months.

A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient? 1) Avoid giving the patient a complete bed bath. 2) Limit the amount of time spent with the patient. 3) Allow extra time for the patient to express feelings. 4) Do not allow anyone to visit the patient.

ANS: 2 When caring for a patient with a radiation implant, the nurse should organize nursing care to limit the amount of time with the patient to limit radiation exposure. The nurse must meet the patient's personal hygiene needs by bathing the patient, if necessary. The nurse should encourage the patient to express her feelings; however, she should limit her contact with the patient. Pregnant women should not visit the patient; however, others may visit as long as they uphold the principles of time, distance, and shielding. PTS: 1 DIF: Moderate REF: p. 660 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

1. Which of the following is/are an appropriate goal(s) for a patient with urinary incontinence? Choose all that apply. 1) Increase the intake of citrus fruits. 2) Maintain daily oral fluids to 8 to 10 servings per day. 3) Limit daily caffeine intake to less than 100 mg. 4) Engage in high-impact, aerobic exercise.

ANS: 2, 3 The nurse should encourage lifestyle changes such as limiting caffeine intake to fewer than 100 mg per day; limiting intake of alcohol, artificial sweeteners, spicy foods, and citrus fruit; and maintaining daily oral fluid intake to 8 to 10 servings per day. High-impact exercise can be associated with stress incontinence for those with weakened pelvic muscles that support the bladder and urethra.

Which point(s) should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply. 1) Make sure the child sleeps on his back at night. 2) Keep the telephone number of the poison control center accessible. 3) Use a front-facing car seat placed in the back seat of the car. 4) Keep syrup of ipecac on hand in case of accidental poisoning.

ANS: 2, 3 The nurse should teach the mother of a toddler to keep the telephone number of the poison control center accessible because toddlers are at risk for accidental poisonings. Toddlers should also have front-facing car seats. Syrup of ipecac is no longer recommended to induce emesis after poisonings. Infants, not toddlers, should sleep on their backs to prevent sudden infant death syndrome. PTS: 1 DIF: Moderate REF: pp. 664, 670 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

3. The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patients rectum? Choose all that apply. 1) 2 in (5.1 cm) 2) 3 in (7.6 cm) 3) 4 in (10.2 cm) 4) 5 in (12.7 cm)

ANS: 2, 3 When administering an enema, the nurse should insert the tubing about 3 to 4 inches into the patients rectum. Two inches would not be effective because it would not place the fluid high enough in the rectum. Five inches is too much.

The World Health Organization's definition of health includes which of the following? Choose all that apply. 1) Absence of disease 2) Physical well-being 3) Mental well-being 4) Social well-being

ANS: 2, 3, 4 The World Health Organization defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. PTS:1DIF:EasyREF:p. 878 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall

6. The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take? 1) Do nothing; this is normal postoperative urine output. 2) Increase the infusion rate of the patients IV fluids. 3) Notify the provider about the patients oliguria. 4) Administer the patients routine diuretic dose early.

ANS: 3 50 mL in 2 hours is not normal output. The kidneys typically produce 60 mL of urine per hour. Therefore, the nurse should notify the provider when the patient shows diminished urine output (oliguria). Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. The nurse cannot provide increased IV fluids without a providers order. The nurse should not administer any medications before the scheduled time without a prescription. The provider may hold the patients scheduled dose of diuretic if he determines that the patient is experiencing deficient fluid volume.

which of the following is a disadvantage of paper health records? 1)Assist collaboration 2)Provide cautionary reminders 3)Are sometimes illegible 4)Serve as a resource

ANS: 3 A disadvantage of paper documentation systems is that they are sometimes illegible. This increases the risk for medication administration and other errors, as well as taking nurses' time to decipher handwriting and call providers.

17. Which is a key treatment intervention for the patient admitted with diverticulitis? 1) Antacid 2) Antidiarrheal agent 3) Antibiotic therapy 4) NSAIDs

ANS: 3 A key treatment for diverticulitis (an infected diverticulum) is antibiotic therapy; if antibiotic therapy is ineffective, surgery may be necessary. Antacids, antidiarrheal agents, and NSAIDs are not indicated for treatment of diverticulitis.

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? 1)It involves a cooperative effort among various disciplines. 2)The system requires diligence in maintaining a current problem list. 3)Data may be fragmented and scattered throughout the chart. 4)It allows the nurse to provide information in an unorganized manner

ANS: 3 A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.

6. A nurse is teaching wellness to a womens group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce servings)? 1) 3 to 4 servings a day 2) 5 to 6 servings a day 3) 7 to 8 servings a day 4) 9 to 10 servings a day

ANS: 3 A minimum of 7 to 8 servings of fluid should be consumed each day to promote healthy bowel function.

Which of the following is an example of an illness prevention activity? Select all that apply. 1)Encouraging the use of a food diary 2)Joining a cancer support group 3)Administering immunization for HPV 4)Teaching a diabetic patient about his diet

ANS: 3 Administering immunization for HPV is an example of illness prevention. Although cancer is a disease, it is assumed that a person joining a support group would already have the disease; therefore, this is not disease prevention but treatment. Illness-prevention activities focus on avoiding a specific disease. A food diary is a health-promotion activity. Teaching a diabetic patient about diet is a treatment for diabetes; the patient already has diabetes, so it cannot prevent diabetes. PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in text KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Application

7. A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient? 1) Stop taking the drug immediately if diarrhea develops. 2) Take an antidiarrheal agent, such as diphenoxylate. 3) Consume yogurt daily while taking the antibiotic. 4) Increase your intake of fiber until the diarrhea stops.

ANS: 3 Antibiotics such as cephalexin, given to combat infection, decrease the normal flora in the colon that cause diarrhea. Bacterial populations can be maintained by encouraging the patient to consume yogurt daily while taking the drugs. Diarrhea is a common adverse effect of antibiotics; stopping the drug is not necessary. The patient should not be encouraged to take an antidiarrheal agent at this time. Increasing the intake of fiber combats constipation, not diarrhea.

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? 1) "Record how much the patient drinks today, please." 2) "Take the patient's vital signs every 2 hours today." 3) "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)." 4) "Assist the patient with all of her meals."

ANS: 3 Clear communication about a task (such as "Take the patient's temperature . . . ") tells the NAP exactly what the task is, the specific time it needs to be done, and the method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation. PTS:1DIF:ModerateREF:p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

The school nurse at a local elementary school is performing physical fitness assessments on the third-grade children. When assessing students' cardiorespiratory fitness, the most appropriate test is to have the students: 1) Step up and down on a 12-inch bench. 2) Perform the sit-and-reach test. 3) Run a mile without stopping, if they can. 4) Perform range-of-motion exercises.

ANS: 3 Field tests for running are good for children and can be utilized when assessing cardiorespiratory fitness. The step test is appropriate for adults. The 12-inch bench height is too high for young children. The sit-and-reach test as well as range-of-motion exercises would be appropriate when assessing flexibility. PTS:1DIF:ModerateREF:pp. 884-885 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse take first? 1) Administer a dose of syrup of ipecac. 2) Administer activated charcoal immediately. 3) Give water to the child immediately. 4) Call the nearest poison control center.

ANS: 3 If the child is awake and able to swallow, and the child has swallowed a household chemical, give one-half glassful of water immediately. After giving the water, call the poison control center. The American Academy of Pediatrics does not advise giving syrup of ipecac. Emergency departments have stopped using ipecac in favor of activated charcoal, which binds to poison in the stomach and prevents it from entering the bloodstream. Continued vomiting caused by syrup of ipecac may later result in the child being unable to tolerate activated charcoal or other poison treatments. No one can tell how much a child vomits, and therefore, no one would know if all the poison was eliminated from the stomach. There is also potential for misuse by bulimics. The poison control center may recommend activated charcoal, depending upon the agent ingested. PTS: 1 DIF: Difficult REF: ESG, Chapter 23, Table 23-2, "Sources and Medical Treatment for Commonly Ingested Poisons" KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

For which range of time must a nurse wash her hands before working in the operating room? 1) 1 to 2 minutes 2) 2 to 4 minutes 3) 2 to 6 minutes 4) 6 to 10 minutes

ANS: 3 In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of soap used. PTS:1DIF:EasyREF:p. 639 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

13. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test? 1) Vitamin D 2) Iron 3) Vitamin C 4) Thiamine

ANS: 3 Ingestion of vitamin C can produce a false-negative fecal occult blood test; ingestion of vitamin D, iron, and thiamine does not. Iron can lead to a false-positive result.

The muscle strength of a woman weighing 132 pounds who is able to lift 72 pounds would be recorded as 0.55. The nurse explains this to the client as the 1) Ratio of weight lifted divided by body weight 2) Measure of weight pushed divided by BMI 3) Ability of a muscle to perform repeated movements 4) Ability to move a joint through its range of motion

ANS: 3 Muscle strength measures the amount of weight a muscle (or group of muscles) can move at one time. This is recorded as a ratio of weight pushed (or lifted) divided by body weight. A woman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or 0.55. PTS:1DIF:ModerateREF:pp. 884-885 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

Why is a lotion without petroleum preferred over a petroleum-based product as a skin protectant? 1) It prevents microorganisms from adhering to the skin. 2) It facilitates the absorption of latex proteins through the skin. 3) It decreases the risk of latex allergies. 4) It prevents the skin from drying and chaffing.

ANS: 3 Non-petroleum-based lotion is preferred because it prevents the absorption of latex proteins through the skin, which can cause latex allergy. Both types of lotion help prevent the skin from drying and becoming chafed. Neither prevents microorganisms from adhering to the skin. PTS: 1 DIF: Moderate REF: p. 634[answer not directly given in the text. Answer must be inferred from the content.] KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour PRN pain. When should the nurse administer the medication? 1)Every hour around-the-clock 2)Immediately after taking off the order 3)As needed, but not more than once per hour 4)1 hour after the last administered dose

ANS: 3 PRN is the abbreviation for "as needed." The nurse should administer the medication after assessing that the patient needs the medication or the patient requests it and at least 1 hour has elapsed since the last dose. STAT medications must be administered immediately.

Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds. 3) washes hands only when leaving each room. 4) uses cold water for medical asepsis.

ANS: 3 Patients acquire infection by contact with other patients, family members, and healthcare equipment. But most infection among patients is spread through the hands of healthcare workers. Hand washing interrupts the transmission and should be done before and after all contact with patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use antibacterial soap with warm water to remove dirt and debris from the skin surface. When no visible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15 seconds. PTS:1DIF:EasyREF:p. 618 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension

What is the most frequent cause of the spread of infection among institutionalized patients? 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of healthcare workers 4) Exposure from family members

ANS: 3 Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of these are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing infection among patients are spread by direct contact on the hands of healthcare workers. PTS:1DIF:EasyREF:p. 609 KEY:Nursing process: Implementation | Client need: SECE | Cognitive level: Recall

21. A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, nurse should teach the patient to: 1) Call the primary care provider if the stoma becomes pale, dusky, or black. 2) Limit the intake of gas-forming foods such as cabbage, onions, and fish. 3) Irrigate the stoma to produce a bowel movement on a schedule. 4) Avoid returning to the use of an ostomy appliance if he becomes ill.

ANS: 3 Patients with an ostomy in the descending or sigmoid colon may use colostomy irrigation as a means to control and schedule bowel evacuation and possibly eliminate the need to wear an ostomy pouch. Limiting the intake of gas-forming foods is a good idea from a social perspective; however, it does not help achieve the goal of having regular bowel movements and thus, eliminating the need to wear a pouch. When illness occurs, it may be difficult to control the output, so the patient can use an ostomy appliance. This will not make it more difficult to schedule the bowel movements after the illness passes.

Which type of managed care allows patients the greatest choice of providers, medications, and medical devices? 1)Health maintenance organization 2)Integrated delivery network 3)Preferred provider organization 4)Employment-based private insurance

ANS: 3 Preferred provider organizations are a form of managed care that allows the patient a greater choice of providers, medications, and medical devices within the designated list. Health maintenance organizations allow the patient to choose a primary care provider within the organization to coordinate his care. This type of program will only reimburse medical care when the patient has first obtained a referral from the primary provider. Integrated delivery networks combine providers, healthcare facilities, pharmaceuticals, and services into one system, and the patient must remain within the system to receive care. Employment-based private insurance is not a managed care organization. PTS:1DIF:EasyREF:ESG, Chapter 1, "Healthcare Delivery Systems, Expanded Discussion," "How Do Healthcare Policy and Reform Efforts Affect Care?"

A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? 1) Primary prevention 2) Secondary prevention 3) Tertiary prevention 4) Health promotion

ANS: 3 Primary prevention activities are designed to prevent or slow the onset of disease. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of primary-level interventions. Secondary prevention activities detect illness so it can be treated in the early stages. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. The patient has an established disease and is receiving care to stop the disease from progressing. PTS:1DIFgrinifficultREF:p. 879 KEY:Nursing process: Planning | Client need: PSI | Cognitive level: Application

A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has "learned what to do." He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him? 1) "By now you have successfully completed the steps of the change process. You should be able to successfully lose the rest of the weight on your own." 2) "Although you have learned some healthy habits, you will need at least another 6 weeks before you can quit the program and have success." 3) "You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle." 4) "You have entered the 'determination stage' and are ready to make positive changes that you can keep for the rest of your life. If you need additional help, you can come back at a later time."

ANS: 3 Prochaska and Diclemente identified four stages of change: the contemplation stage, the determination stage, the action stage, and the maintenance stage. This patient demonstrates behaviors typical of the action stage. If a participant exits a program before the end of the maintenance stage, relapse is likely to occur as the individual resumes his previous lifestyle. PTS:1DIF:ModerateREF:pp. 881-882 KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare? 1)Reduced usage of diagnostics using advanced technology 2)Decreased number of unnecessary visits to the emergency department 3)Improved patient compliance with prescribed treatments 4)Increased usage of complementary alternative therapies

ANS: 3 Studies demonstrate that APNs have improved patient outcomes over those of physicians, including increased patient understanding and cooperation with treatments and decreased need for hospitalizations. No well-known, scientific studies support APNs' effect on the use of advanced technology. No well-known, scientific studies support APNs' effect on the frequency of emergency department visits. No well-known, scientific studies support APNs' effect on the use of alternative therapies. PTS:1DIF:ModerateREF:p. 20

Which set of topics makes up a hand-off report given in a recommended format? 1)Data-action-response 2)Subjective-objective-assessment-plan 3)Situation-background-assessment-recommendation 4)Patient-diagnosis-medications-activity

ANS: 3 The SBAR (situation-background-assessment-recommendation) technique is used as a mechanism to give a hand-off report by enabling a focused communication between healthcare team members. DAR is used in Focus Charting®, and SOAP is a method for documenting nursing care. The nursing admission assessment is completed and documented at the time of admission.

Nursing was described as a distinct occupation in the sacred books of which faith? 1)Buddhism 2)Christianity 3)Hinduism 4)Judaism

ANS: 3 The Vedas, the sacred books of the Hindu faith, described Indian healthcare practices and were the earliest writings of a distinct nursing occupation. PTS:1DIF:EasyREF:p. 7

15. The nurse notes that a patients indwelling urinary catheter tubing contains sediment and crusting at the meatus. Which action should the nurse take? 1) Notify the provider immediately. 2) Flush the catheter tubing with saline solution. 3) Replace the indwelling urinary catheter. 4) Encourage fluids that increase urine acidity.

ANS: 3 The catheter needs to be changed when sediment collects in the tubing or catheter and crusting at the meatus occurs. It is not necessary to notify the provider immediately. The nurse should not flush the catheter tubing. The patient should be encouraged to consume fluids that increase urine acidity to prevent urinary tract infection; however, it will not help clear the catheter tubing of sediment.

A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? 1) Phagocytosis 2) Complement cascade 3) Inflammation 4) Immunity

ANS: 3 The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. The secondary defenses phagocytosis (process by which white blood cells engulf and destroy pathogens) and the complement cascade (process by which blood proteins trigger the release of chemicals that attack the cell membranes of pathogens) do not produce visible findings. Immunity is a tertiary defense that protects the body from future infection. PTS:1DIFgrinifficultREF:p. 610 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

Which criterion might be used in structure evaluation? 1) Staff refrains from sharing computer password. 2) Healthcare provider washes hands with each client contact. 3) A defibrillator is accessible on each client care area. 4) Nurse verifies client identification before initiating care.

ANS: 3 The criterion that states "a defibrillator is present on each client care area" is associated with structure evaluation. "Refrains from sharing computer password," "washes hands before each client contact," and "verifies client identification before initiating care" are criteria associated with process evaluation. PTS:1DIF:ModerateREF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis

23. The nurse is teaching an older female patient how to manage urge incontinence at home. What is the first-line approach to reducing involuntary leakage of urine? 1) Insertion of a pessary 2) Intermittent self-catheterization 3) Bladder training 4) Anticholinergic medication

ANS: 3 The goal of bladder training is to enable the patient to hold increasingly greater volumes of urine in the bladder and to increase the interval between voiding. This involves patient teaching, scheduled voiding, and self-monitoring using a voiding diary. In addition to teaching the mechanisms of urination, teach distraction and relaxation strategies to help inhibit the urge to void. Other techniques include deep breathing and guided imagery. A pessary is an incontinence device that is inserted into the vagina to reduce organ prolapse or pressure on the bladder. Clean, intermittent self-catheterization is a good option for managing incontinence that is resistant to conservative measure, such as bladder training, Kegel exercises, lifestyle modification, and medication. Anticholinergic medication can be highly effective for improving urinary incontinence. However, more conservative measures, such as timed voiding and Kegel exercises, are recommended first.

The nurse has just finished documenting that he removed a patient's nasogastric tube. Which is the next logical step in the nursing process? 1) Assessment 2) Planning 3) Evaluation 4) Diagnosis

ANS: 3 The implementation phase ends when you document nursing actions on the client's chart. Implementation evolves into the evaluation step when you document the client's response to your interventions. As a general rule, the steps in order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, and evaluation. PTS:1DIF:EasyREF:p. 125 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension

19. Which task can the nurse safely delegate to the nursing assistive personnel? 1) Palpating the bladder of a patient who is unable to void 2) Administering a continuous bladder irrigation 3) Providing indwelling urinary catheter care 4) Obtaining the patients history and physical assessment

ANS: 3 The nurse can safely delegate indwelling urinary catheter care to nursing assistive personnel who are adequately trained to do so. Palpating the bladder, administering continuous bladder irrigation, and obtaining the patients history and physical assessment involve the critical thinking skills of a professional nurse.

The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following? 1)Functional 2)Primary 3)Case method 4)Team

ANS: 3 The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift. When the functional nursing model is employed, care is compartmentalized, and each task is assigned to a staff member with the appropriate knowledge and skills. In primary nursing, one nurse plans the care for a group of patients round-the-clock. The primary nurse assesses the patient and develops the plan of care. When he or she is working, he or she provides care for those patients that he or she is responsible for. In his or her absence, the associate nurses deliver care. Although the nurse in this case could possibly be a primary nurse, there are not enough data to confidently infer that. If the team nursing approach is utilized, a licensed nurse (RN or LVN) is paired with a nursing assistant. The pair is then assigned to a group of patients. PTS:1DIF:ModerateREF:ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "What Models of Care Are Used to Provide Nursing Care?"

A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed? 1) Administer the medication as prescribed. 2) Hold the medication and notify the prescriber. 3) Consult with a pharmacist before administering it. 4) Ask the patient's nurse for information about the medication.

ANS: 3 The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as prescribed, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatment—many drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication. PTS:1DIF:ModerateREF:p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

The nurse makes a mistake while documenting in the patient's health record. Which action should the nurse take? 1)Use an opaque white fluid to cover the documentation error. 2)Completely cover the documentation error with black ink. 3)Draw a line through the error and initial the change. 4)Use correction tape to make the documentation correct.

ANS: 3 The nurse should draw a single line through the documentation error and place her initials next to the change. In some institutions, the nurse must also write the words "error" or "mistaken entry" above the error. The nurse should never use opaque cover-up liquid or correction tape. It is not acceptable to alter the patient's health record as though the error was not made. Making note of the correction in documentation makes it clear to others what happened.

4. Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) Milk and cheese. 2) Bread and pasta. 3) Fruits and vegetables. 4) Lean meats.

ANS: 3 The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.

9. What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowlers

ANS: 3 The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal recumbent position). If the patient is unable to assume this position, the nurse should help the patient to a side-lying position. Modified Trendelenburg position is used for central venous catheter insertion. Prone position is sometimes used to improve oxygenation in patients with adult respiratory distress syndrome. Semi-Fowlers position is used to prevent aspiration in those receiving enteral feedings.

A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse is(are) advisable? 1) Reassure the patient by entering the room alone. 2) Ask the patient if he is carrying any weapons. 3) Stay between the patient and the door; keep the door open. 4) Make eye contact while stating firmly "I will not tolerate cursing and threats."

ANS: 3 The nurse should keep the door open and position herself so that the patient cannot block her exit from the room (stay between the patient and the door). The nurse should not enter a room alone with an angry patient. The progression to physical violence is first anxiety, then verbal aggression, and finally physical aggression. The nurse's first priority in this situation is her own safety and the safety of others in the environment. The object is to relieve the patient's anxiety and not respond to anger with anger. Questioning about weapons, or being firm and defending against verbal aggression will likely provoke even more anger from the patient. The nurse must be calm and reassuring. PTS:1DIFgrinifficultREF:p. 674 KEY: Nursing process: N/A | Client need: PSI | Cognitive level: Application

A patient is admitted to the emergency department with a stroke. After being stabilized, the patient's needs are best met if the nurse documents a care plan that provides for 1)Acute interventions 2)Patient teaching 3)Discharge needs 4)Family health data

ANS: 3 The patient's potential discharge needs should be evaluated when the patient first enters the healthcare facility. After the patient is admitted, discharge needs should be continually reevaluated and documented throughout the patient's hospitalization.

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? 1)Hypertension 2)Rheumatoid arthritis 3)Postoperative colon resection 4)Follow all three plans

ANS: 3 The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patient's other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care.

At 1000 on 11/14/10, the nurse takes a telephone order for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? 1)11/14/13 at 1200 2)11/14/13 at 2200 3)11/15/13 at 1000 4)11/16/13 at 1000

ANS: 3 The prescriber must countersign all verbal and telephone orders within 24 hours.

A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing? 1) Incubation 2) Prodromal 3) Decline 4) Convalescence

ANS: 3 The stage of decline occurs when the patient's immune defenses, along with any medical therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between the invasion by the organism and the onset of symptoms. During the incubation stage, the patient does not know he is infected and is capable of infecting others. The prodromal stage is characterized by the first appearance of vague symptoms. Convalescence is characterized by tissue repair and a return to healing as the organisms disappear. PTS:1DIF:ModerateREF:p. 609 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

What is the most influential factor that has shaped the nursing profession? 1)Physicians' need for handmaidens 2)Societal need for healthcare outside the home 3)Military demand for nurses in the field 4)Germ theory influence on sanitation

ANS: 3 Throughout the centuries, stability of the government has been related to the success of the military to protect or extend its domain. As the survival and well-being of soldiers is critical, nurses provided healthcare to the sick and injured at the battle site. The physician's handmaiden was/is a nursing stereotype rather than an influence on nursing. Although there has been need for healthcare outside the home throughout history, this has more influence on the development of hospitals than on nursing; this need provided one more setting for nursing work. Germ theory and sanitation helped to improve healthcare but did not shape nursing. PTS: 1 DIF: Moderate REF: pp. 9-10 KEY: Nursing process: N/A Client need: N/A | Cognitive level: Recall

24. What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter? 1) Use antiseptic wipes to cleanse the meatus prior to obtaining the sample. 2) Briefly disconnect the catheter from the drainage tube to obtain the sample. 3) Withdraw urine through the port using a needleless access device. 4) Obtain the urine specimen directly from the collection bag.

ANS: 3 To obtain a specimen from an indwelling catheter, insert the needleless access device with a 20- or 30-mL syringe into the specimen port, and aspirate to withdraw the amount of urine you need. Wiping the meatus with an antiseptic material helps to minimize contamination for a clean-catch voided specimen, not a sample collected from a closed system such as an indwelling catheter system. Never disconnect the catheter from the drainage tube to obtain a sample. Interrupting the system creates a portal of entry for pathogens, thereby increasing the risk of contamination. Do not take the specimen from the collection bag because that urine may be several hours old.

In which situation would using standard precautions be adequate? Select all that apply. 1) While interviewing a client with a productive cough 2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter

ANS: 3, 4 Standard precautions should be instituted with all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a client, if the disease is not spread by air or droplets, there is no likelihood of the nurse's encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne precautions would be needed in addition to standard precautions. If giving a complete bed bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely assisting a client to perform those ADLs, it is not necessary. No exposure to body fluids is likely when helping a client to ambulate after surgery. PTS: 1 DIF: Easy REF: pp. 619-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. 1) Question the order because the patient must remain in isolation. 2) Place an N-95 respirator mask on the patient and transport him to the test. 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport.

ANS: 3, 4 Transporting a patient who requires airborne precautions should be limited; however, when necessary the patient should wear a surgical mask (an N-95 respirator mask is not required) that covers the mouth and nose to prevent the spread of infection. Moreover, the department where the patient is being transported should be notified about the precautions before transport. PTS: 1 DIF: Difficult REF: pp. 623-624 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

2. A patient who has been immobile since sustaining injuries in a motor vehicle accident complains of constipation. The nurse encourages him to consume eight to ten 8-ounce servings of fluid daily. Which fluid(s) should the patient avoid because of the diuretic effect? Choose all that apply. 1) Cranberry juice 2) Water 3) Coffee 4) Ginger ale 5) Tea

ANS: 3, 5 Coffee, tea, and caffeine-containing sodas should be avoided because caffeine promotes diuresis, placing the patient at further risk for constipation. Water is the preferred fluid; however, fruit juices and decaffeinated sodas are also acceptable.

A client informs the nurse that he has quit smoking because his father died from lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following? 1) Healthy living 2) Health promotion 3) Wellness behaviors 4) Health protection

ANS: 4 Although health promotion and health protection may involve the same activities, their difference lies in the motivation for action. Health protection is motivated by a desire to avoid illness. Health promotion is motivated by the desire to increase wellness. Smoking cessation may also be a wellness behavior and may be considered a step toward healthy living; however, neither of these addresses motivation for action. PTS:1DIF:ModerateREF:p. 879 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension

An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him? 1)Acute care facility 2)Ambulatory care facility 3)Extended care facility 4)Assisted living facility

ANS: 4 Assisted living facilities are intended for those who are able to perform self-care activities but who require assistance with meals, housekeeping, or medications. Acute care facilities focus on preventing illnesses and treating acute problems. These facilities include physicians' offices, clinics, and diagnostic centers. Ambulatory care facilities provide outpatient care. Clients live at home or in nonhospital settings and come to the site for care. Ambulatory care facilities include private health and medical offices, clinics, surgery centers, and outpatient therapy centers. Extended care facilities typically provide long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions. PTS:1DIF:EasyREF:p. 18; ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "Where is Healthcare Provided?"

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1) Teaching the client that he must lose weight to control his blood sugar 2) Informing the client he must exercise at least three times per week 3) Explaining to the client that he must come to the diabetic clinic weekly 4) Determining the client's main concerns about his diabetes

ANS: 4 Determining the client's main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client's support systems and resources, not just tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior. PTS:1DIF:ModerateREF: p. 122 KEY: Nursing process: Planning interventions | Client need: PHSI | Cognitive level: Analysis

17. A patient is admitted with high BUN and creatinine levels, low blood pH, and elevated serum potassium level. Based on these laboratory findings the nurse suspects which diagnosis? 1) Cystitis 2) Renal calculi 3) Enuresis 4) Renal failure

ANS: 4 Elevated BUN, creatinine, and serum potassium levels and low blood pH are signs of renal failure. Cystitis is an infection of the bladder and would not result in abnormal renal function. Renal calculi typically produce blood in the urine but do not lead to marked renal dysfunction and failure. Enuresis is involuntary urination, particularly common in children, and does not produce renal dysfunction. The cause of enuresis is often emotional, developmental, or trauma related.

10. The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patients abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds

ANS: 4 Hypoactive bowel sounds are low-pitched, infrequent, and quiet. An abdominal bruit is a hollow, blowing sound found over an artery, such as the iliac artery. Normal bowel sounds are high pitched with approximately 5 to 35 gurgles occurring every minute. Hyperactive bowel sounds are very high pitched and more frequent than normal bowel sounds.

The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would most likely be found in a test of immunoglobin levels? 1) IgA 2) IgE 3) IgG 4) IgM

ANS: 4 IgM are the first antibodies made in response to infection. IgE is the antibody primarily responsible for this allergic response. IgA antibodies protect the body in fighting viral and bacterial infections, and appear later. IgG antibodies also appear later—perhaps up to 10 days later. PTS:1DIF:ModerateREF:p. 612 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

Which intervention depends almost entirely on the client's adhering to the therapy? 1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet

ANS: 4 Instituting and adhering to a low-fat, low-calorie diet is an intervention that depends almost entirely on the client's adhering to the therapy. Client cooperation is necessary for performing the other interventions, but the interventions do not depend on the client to the same extent. PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Analysis

3. Which urine specific gravity would be expected in a patient admitted with dehydration? 1) 1.002 2) 1.010 3) 1.025 4) 1.030

ANS: 4 Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity less than 1.010 indicates fluid volume excess, such as when the patient has fluid overload (too much IV fluid) or when the kidneys fail to concentrate urine. Specific gravity greater than 1.025 is a sign of deficient fluid volume that occurs, for example, as a result of blood loss or dehydration.

Which of the following is the most important reason to develop a definition of nursing? 1)Recruit more informed people into the nursing profession 2)Evaluate the degree of role satisfaction 3)Dispel the stereotypical images of nurses and nursing 4)Differentiate nursing activities from those of other health professionals

ANS: 4 Nursing organization leaders think it is important to develop a definition of nursing to bring value and understanding to the profession, differentiate nursing activities from those of other health professionals, and help student nurses understand what is expected of them. A definition of nursing would not be likely to increase the number of informed people recruited into nursing. A definition of nursing would do little to improve the nurse's role satisfaction. Although a definition of nursing might contribute to fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals) exist to counteract it. PTS:1DIF:EasyREF:V1, pp. 11-13; students must infer from content

8. Which collaborative interventions will help prevent paralytic ileus in a patient who underwent right hemicolectomy for colon cancer? 1) Administer morphine 4 mg IV every 2 hours for pain. 2) Administer IV fluids at 125 mL/hr. 3) Insert an indwelling urinary catheter to monitor I&O. 4) Keep the patient NPO until bowel sounds return.

ANS: 4 Patients who require bowel surgery typically remain NPO until peristalsis returns, helping to prevent paralytic ileus, a complication that can occur after the bowel is surgically manipulated. Administering morphine promotes comfort but may increase the risk of ileus. Administering IV fluids prevents dehydration but does not directly prevent ileus. Inserting an indwelling urinary catheter prevents urine retention and facilitates monitoring postoperative urine output.

Which nursing intervention is best individualized to meet the needs of a specific client? 1) Suction the client every 2 hours per unit policy. 2) Use incentive spirometry every hour while awake per postoperative protocols. 3) Institute swallowing precautions. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

ANS: 4 Positioning the client in the chair for meals considers the client's desire to be out of bed for dinner, so it is obviously individualized. An intervention performed according to unit policy or protocols is not necessarily individualized. "Institute swallowing precautions" does not provide instructions for the specific actions needed to do that for "this particular" client. PTS:1DIF:ModerateREF:p. 118; high-level question, answer not given verbatim KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Application

A patient infected with a virus but who does not have any outward sign of the disease is considered a: 1) pathogen. 2) fomite. 3) vector. 4) carrier.

ANS: 4 Some people might harbor a pathogenic organism, such as the human immunodeficiency virus, within their bodies and yet do not acquire the disease/infection. These individuals, called carriers, have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a pathogen to a susceptible host through a portal for entry into the body. An example of a vector is a mosquito or tick that bites or stings. PTS:1DIF:ModerateREF:p. 607 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

10. A patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this complaint in the patients healthcare record? 1) Transient incontinence 2) Overflow incontinence 3) Urge incontinence 4) Stress incontinence

ANS: 4 Stress incontinence is an involuntary loss of urine that occurs with increased intra-abdominal pressure. Activities that typically produce the symptom include sneezing, coughing, laughing, lifting, and exercise. Transient incontinence is a short-term incontinence that is expected to resolve spontaneously. It is typically caused by urinary tract infection or medications, such as diuretics. Overflow incontinence is the loss of urine when the bladder becomes distended; it is commonly associated with fecal impaction, enlarged prostate, and neurological conditions. Urge incontinence is the involuntary loss of urine associated with a strong urge to void.

3. The nurse educates a patient about the primary risk factors for irritable bowel syndrome. Which behavior by the patient would be evidence of learning? The patient: 1) Reduces her intake of gluten-containing products. 2) Does not consume foods that contain lactose. 3) Consumes only two servings of caffeinated beverages per day. 4) Takes measures to reduce her stress level.

ANS: 4 Stress is a primary factor in the development of irritable bowel syndrome. Other risk factors include caffeine consumption and lactose intolerance; however, they are not primary risk factors. Celiac disease is associated with gluten intake.

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? 1)Study the discharge plan. 2)Check the graphic data for vital signs. 3)Examine the history and physical. 4)Look for an advance directive.

ANS: 4 The advance directive, which should be located in a special section of the patient's medical record, should be examined first because the patient's symptoms indicate that he may need to be resuscitated. The advanced directive contains information about the patient's wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data are to record assessment done frequently, such as vital signs. The history and physical provide a detailed summary of the patient's current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel? 1) Assessing the patient's status 2) Determining the need for restraint 3) Evaluating the patient's response to restraints 4) Applying and removing the restraints

ANS: 4 The nurse can delegate applying and removing the restraints, skin care, and checking for skin breakdown. The nurse responsible for care of the patient must assess the patient's need for restraint and the patient's status and must evaluate the patient's response to restraints. PTS: 1 DIF: Moderate REF: p. 675 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour? 1) At the end of the shift 2) Every 24 hours 3) Every 4 hours 4) Every hour

ANS: 4 The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patient's urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient. PTS:1DIF:EasyREF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning? 1) Store medications on countertops out of the child's reach. 2) Purchase medication in child-resistant containers 3) Take medications in front of the child, and explain that they are for adults only. 4) Never leave the child unattended around medications or cleaning solutions.

ANS: 4 The nurse should instruct the mother to avoid leaving her child unattended around medications or cleaners even for a moment. Medications should never be stored on kitchen counters or bathroom surfaces because children love to explore and climb and can get into them. The nurse should explain that medications should not be taken in front of the child because children imitate adult behavior. The nurse should reinforce that although child-resistant containers are a deterrent, they are not foolproof because many toddlers and preschoolers can open them. PTS:1DIF:ModerateREF:p. 665 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

12. Which intervention should the nurse take first to promote micturition in a patient who is having difficulty voiding? 1) Insert an indwelling urinary catheter. 2) Notify the provider immediately. 3) Insert an intermittent, straight catheter. 4) Pour warm water over the patients perineum.

ANS: 4 The nurse should perform independent nursing measures, such as pouring warm water over the patients perineum before notifying the provider. If nursing measures fail, the nurse should notify the provider. The provider may order an indwelling urinary catheter or a straight catheter to relieve the patients urinary retention.

To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? 1) When fingers feel sticky 2) After 5 to 10 seconds 3) When leaving the client's room 4) Once fingers and hands feel dry

ANS: 4 The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution dries, usually 10 to 15 seconds, to ensure effectiveness. PTS: 1 DIF: Easy REF: p. 634 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

Despite less-restrictive interventions, a patient's behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation? 1) Obtain a physician's order before applying restraints. 2) Monitor the patient's status every 4 hours while restrained. 3) Release the restraints and check circulation every hour. 4) Continually reevaluate the patient's need for restraint.

ANS: 4 The patient must be continually monitored, and the need for restraint must be continually reevaluated. As a rule, a medical order should be obtained before applying restraints. However, in an emergency, the nurse is permitted to apply restraints for behavior management, but a physician or advanced practice nurse must then evaluate the patient within 1 hour of restraint application. The order for restraint must be renewed daily. The restraints must be released at least every 2 hours, and circulation must be checked. PTS: 1 DIF: Difficult REF: pp. 679-681 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

Which member of the healthcare team typically serves as the case manager? 1)Occupational therapist 2)Physician 3)Physician's assistant 4)Registered nurse

ANS: 4 Typically, registered nurses serve as case managers for patients with specific diagnoses. Their role is coordinator of care across the healthcare system. The occupational therapist, physician, and physician's assistant all serve on the healthcare team and take direction from the case manager. PTS: 1 DIF: Easy REF: ESG, Chapter 1, "Healthcare Delivery Systems—Expanded Discussion," "What Healthcare Providers Will You Work With?"

The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best? 1) Continue to monitor the pump to see if the crack worsens. 2) Place the pump back on the utility room shelf. 3) A small crack poses no danger so continue using the pump. 4) Clearly label the pump and send it for repair.

ANS: 4 Whenever an electrical safety hazard is suspected or visible, the nurse should label the malfunctioning equipment and send it for repair or inspection. Continuing to use the IV infusion pump or any other equipment places the patient at risk for injury. Placing the pump back on the shelf places other healthcare team members at risk for electrical injury if they attempt to use the equipment. PTS:1DIF:EasyREF:p. 673 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

19. A patient with a colostomy complains to the nurse, I am noticing really bad odors coming from my pouch. To help control odor, which foods should the nurse advise him to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4) Yogurt and parsley

ANS: 4 Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy.

2.The nurse is collecting a stool specimen. Arrange the following steps in the order in which the nurse should perform them. Label the steps from A to D, with A being the first step to perform. A. Have the patient defecate into a special container placed under the toilet seat. B. Put on gloves and place the specimen in a specimen container. C. Ask the patient to void to empty the bladder. D. Place a label on the specimen container.

ANS: C, A, B, D The nurse should ask the patient to void and then have him defecate into a special container placed under the toilet seat. Next, the nurse should put on gloves and, using a tongue blade, place the specimen into the container. Finally, she should label the specimen and send it to the laboratory for analysis.

1.When performing an abdominal assessment, what sequence of assessment techniques should the nurse use? Label the steps from A to D, with A being the first step to perform. A. Auscultation B. Palpation C. Percussion D. Inspection

ANS: D, A, C, B When performing an abdominal assessment, the nurse should follow the sequence: inspection, auscultation, percussion, and palpation. Percussion and palpation may stimulate peristalsis, so the techniques with the least contact should be done first.

3.When administering an enema, list the following steps in the order in which they should be performed. Label the steps from A to F, with A being the first step to perform. A. Document the results of the procedure. B. Assess the patient for cramping. C. Insert the tubing about 3 to 4 inches into the rectum. D. Lubricate the tip of the enema tubing generously. E. Raise the container to the correct height and instill the solution at a slow rate. F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.

ANS: D, C, E, B, F, A You must lubricate the tip before inserting the tubing. You would then insert the tubing and begin instilling the solution before assessing for cramping that the instillation might produce. Only after the solution is instilled would you ask the patient to hold the solution. The last action is to document the results of the procedure, after the procedure is finished.

True/false 1. Nurses should obtain information about urinary control from all female patients.

ANS: T All women, especially older women and those who have experienced childbirth, should be screened for different types of urinary incontinence.

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE 1)Reduces the time nurses spend charting 2)Addresses the patient's concerns holistically 3)Establishes an ongoing care plan from admission 4)Is most useful when constructing a timeline of events

NS: 1 An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patient's concerns holistically. PIE charting establishes an ongoing care plan from admission. Narrative charting is especially useful when attempting to construct timelines of events.

Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1) Virus 2) Bacterial spores 3) Yeast 4) Mold

NS: 1, 3, 4 If there is potential for contact with bacterial spores, hands must be washed with soap and water; alcohol-based solutions are ineffective against bacterial spores. PTS:1DIF:ModerateREF:p. 618 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

he patient's health record contains the following provider's order: furosemide 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patient's response to the medication, where would he look? 1)Progress notes 2)Graphic record 3)Narrative notes 4)MAR

NS: 3 The nursing narrative note will contain documentation about the time the medication was administered and the patient's response to the medicine. In contrast, the MAR will only contain documentation about when the medication was given, not the patient's response. The physician's progress note contains documentation about why the furosemide was ordered. The graphic record will not contain charting about the medication but will contain information about the patient's output.