NCLEX / HESI PREP from Adaptive Quizzing NOVICE (flashcard & definition)

What is the most important skill of the nurse leader? Priority setting Time management Clinical decision making Clinical care coordination

Clinical care coordination Rationale The most important leadership skill for a nursing student is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components included in clinical care coordination.

Which religion recommends circumcision before puberty? Islam Mormon Eastern Orthodox Disciples of Christ

Islam Rationale Circumcising the foreskin of the penis before puberty is a cultural recommendation in the Islam community. The Mormon, Eastern Orthodox, and Disciples of Christ communities do not have specific recommendations on circumcision.

While serving as leader, a nurse tells the group, "You should make all decisions concerning the client." Which leadership style is the nurse using? Autocratic Permissive Situational Democratic

Permissive Rationale Permissive leadership (also known as laissez-faire or free-run leadership) involves a leader avoiding responsibility and delegating all decision-making to the group. An autocratic leader makes all decisions. Situational leadership gives the manager flexibility in handling decisions. In democratic leadership, the leader and the group are equally involved in decision-making.

Which religious group practices infant baptism? Jehovah's Witness Seventh-Day Adventist Church of the Brethren United Church of Christ

United Church of Christ Rationale The United Church of Christ religious group practices infant baptism. Jehovah's Witness, Seventh-Day Adventist, and the Church of the Brethren clients do not practice infant baptism.

Which type of home care agency includes Visiting Nurses Association? Official agency Voluntary agency Proprietary agency Hospital-Based agency

Voluntary agency Voluntary agencies were the first to deliver nursing care in the home. Visiting Nurses Associations are the most common examples of voluntary agencies. Official agencies are those supported by tax dollars and are authorized by law to deliver services to a defined area or community. Proprietary agencies are organized to make a profit on their operation. The hospital-based agency usually gets most of its referrals from the hospital itself.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? Keeps the area free of microorganisms. Confines microorganisms to the surgical site. Protects self from microorganisms in the wound. Reduces the risk for growing opportunistic microorganisms.

Keeps the area free of microorganisms Rationale Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound applies to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

Which healthcare system is required after a physical or mental illness, injury, or chemical addiction? Rehabilitation Intensive care Psychiatric facilities Extended care facilities

Rehabilitation Rationale Clients require rehabilitation after a physical illness, mental illness, injury, or chemical addiction. An intensive care unit is required when a client needs close monitoring in addition to medical care. Clients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. An extended care facility provides intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities.

Which member of the hospice care team is responsible for providing respite care to the client's caregiver? Nurse coordinator Spiritual coordinator Volunteer coordinator Bereavement coordinator

Volunteer coordinator Rationale A volunteer coordinator of a hospice care team is responsible for providing respite care to the caregiver of the client. A nurse coordinator manages the client's care, explains the services, and assigns a primary team. A spiritual coordinator serves as a liaison between the client and the spiritual community and coordinates spiritual support. A bereavement coordinator assesses and supports the bereaved survivor and facilitates support groups.

A client has a pulse deficit. Which documentation by the nurse supports this finding? Blood pressure of 130/70 mm Hg indicating pulse deficit of 60. Capillary refill greater than 3 seconds indicating pulse deficit. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8. Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10.

Apical Pulse 86 and radial pulse 78 indicating a pulse deficit of 8 Rationale The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.

Which temperature measurement site is least accurate? Rectal Axillary Tympanic Temporal artery

Axillary Rationale Measuring the temperature using the axillary route provides the least accurate readings.

Which are the most likely physical findings to be seen in a client who is the victim of intimate partner violence? Select all that apply. Burns Abrasions Excoriation Hematomas Human bites

Burns Abrasions Human bites Rationale Physical findings such as burns, abrasions, and human bites are often seen in victims of domestic violence. Abrasions and hematomas are more often seen in abused older adults.

While serving as a leader, the nurse asks the subordinates, "What do you think should be done in this situation?" Which type of leadership is reflected in the nurse's action? Autocratic Situational Democratic Laissez-faire

Democratic Rationale Democratic leadership is a people-centered approach that allows employees and other individuals to be involved in decision-making. This leadership is demonstrated by the nurse asking his or her subordinates questions about care implementation. A leader who uses an autocratic leadership style displays little trust and confidence in employees. Situational leadership offers flexibility to the manager. Laissez-faire leadership involves the nurse avoiding responsibility and delegating decision-making to the group.

Which are the functions of skeletal muscle? Select all that apply. Eye movements Movement of bones Contraction of the heart Changing the diameter of the pupils Movement of substances along ducts

Eye movements Movement of bones Rationale The skeletal muscles help in eye and bone movements. Cardiac muscles help in contraction of the heart. The smooth muscles change the diameter of the pupils and help in the movement of substances along the ducts.

Which health care professionals can become members of the NFLPN? Select all that apply. Registered nurses Licensed practical nurses Licensed vocational nurses Assistive personnel Physicians

Licensed practical nurses Licensed vocational nurses Rationale The NFLPN is the National Federation of Licensed Practical Nurses (NFLPN), an official membership organization for licensed practical nurses and licensed vocational nurses only. Registered nurses, assistive personnel, and physicians are excluded from this health care organization.

Which action is appropriate while assessing the body temperature in a client who is suspected of having hypothermia? Measuring oral temperature with a glass thermometer Measuring rectal temperature with an electronic thermometer Measuring axillary temperature with an electronic thermometer Measuring tympanic temperature with a tympanic thermometer

Measure rectal temperature with an electronic thermometer Rationale Temperature assessed via the rectal route provides an accurate core temperature reading. The use of an electronic thermometer is safer and more accurate when compared to glass thermometer. Assessing oral temperature with a glass thermometer is no longer recommended. The axillary route provides the least accurate temperature readings. The rectal route is preferred than the tympanic route.

A client with terminal cancer approaches his or her health care facility for hospice care. Which member of the hospice care organization is responsible for assessing symptom management of the cancer and recording the response to treatment? Social worker Primary nurse Medical director Hospice pharmacist

Primary Nurse Rationale The primary nurse assesses symptom management and documents the response to the treatment. The social worker evaluates the client's psychosocial needs and serves as a resource for community services. The medical director mediates between the hospice team and attending medical provider. The hospice pharmacist provides drug consultation to the clients.

Which temperature measurement uses a probe with a red tip? Oral Rectal Axillary Tympanic

Rectal Rationale A temperature-processing probe with a red tip is used for rectal temperature measurement. A temperature-processing probe with a blue tip is used for oral temperature measurement. Axillary temperature measurement does not use a probe with a red tip. Tympanic thermometers are used for tympanic temperature measurement.

Which route for measuring temperature is facilitated when the client is in the Sims position? Rectal Axillary Temporal Tympanic

Rectal Rationale Rectal temperature is most easily measured when the client is placed in the Sims position. The supine or sitting position is used to measure body temperature via the axillary route. The supine position is used to measure body temperature via the temporal route. While measuring the tympanic temperature, the client is placed in the sitting or supine position by turning the client's head toward the side, away from the nurse.

What is the role of a chaplain on a rehabilitation team? Recreation planner Vocational planner Spiritual consultant Emotional evaluator

Spiritual consultant Rationale A chaplain is the spiritual consultant on the rehabilitation team. A therapeutic recreation therapist is the recreation planner. A vocational rehabilitation counselor is the vocational planner. A clinical psychologist is the emotional evaluator.

What factors are most important for the nurse to consider when delegating responsibilities? Preferences of the clients and staff Physical layout of the unit and client rooms Staff member's level of education and expertise Client's diagnosis and length of time in the hospital

Staff member's level of education and expertise

Which statement is true regarding factors that affect body temperature? Emotional stress lowers body temperature. Body temperature peaks between 1 am and 4 am. Exercise can increase or decrease body temperature. Women generally have greater variations in body temperature than men.

Women generally have greater variations in body temperature than men. Rationale Women generally have greater variations in body temperature than men. Emotional stress raises body temperature. Body temperature peaks between 4 pm and 6 pm. Exercise raises the body temperature.

A nurse in the health clinic is counseling a college student who was recently diagnosed with asthma. On what aspect of care should the nurse focus? Teaching how to make a room allergy-free. Referring to a support group for individuals with asthma. Arranging with the college to ensure a speedy return to classes. Evaluating whether the necessary lifestyle changes are understood.

Evaluating whether the neccessary lifestyle changes are understood Rationale Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

Which therapy may help ease the pain caused by local recurrence and metastasis associated with breast cancer? Chemotherapy Hormonal therapy Radiation therapy Monoclonal antibody therapy

Radiation Therapy Rationale Radiation therapy may help ease the pain caused by local recurrence and metastasis associated with breast cancer. However, clients who have lymph node involvement or metastasis to distant organs may require chemotherapy. Hormonal therapy may be useful in clients with breast cancer cells that are estrogen receptor positive. Monoclonal antibody therapy may be used to treat metastatic breast cancer in women who overexpress a breast cancer cell antigen called HER2.

Which nursing intervention would benefit a client with hyperthermia? Providing a blanket Reducing the oral fluid intake Removing any external covering Encouraging that the client conduct physical activity

Removing any external covering Rationale Removal of external clothing will benefit a client with hyperthermia. A blanket should be provided to a client with subnormal temperature. In hyperthermia, fluid intake is increased to prevent dehydration. Physical activity should be reduced in a client with hyperthermia.

A client with gastroesophageal reflux is to receive metoclopramide 15 mg orally before meals. The concentrated solution contains 10 mg/mL. How much solution should the nurse administer? Record your answer using one decimal place. ______ mL

1.5 15mg : 10mg/mL = 1.5 Rationale The prescribed dose is 15 mg. The available concentration is 10 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine the appropriate amount of medication to be administered.

A woman in premature labor is prescribed betamethasone to enhance fetal lung maturity. The prescription reads: "Administer betamethasone 12 mg IM daily for 3 days." The betamethasone comes in a vial labeled "6 mg/mL." How many milliliters should the nurse administer each day? Record your answer using a whole number. ______mL

2mL 12 mg : 6mg/mL = 2mL Rationale The prescribed dose is 12 mg. The available concentration is 6 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse should administer with each dose.

The professional obligation of a nurse to assume responsibility for actions is referred to as what? Accountability. Individuality. Responsibility. Bioethics.

Accountability Rationale Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession. Individuality and responsibility are positive characteristics of the nurse but are not necessarily professional obligations. Bioethics is a field of study concerned with the ethics and philosophical implications of certain biological and medical procedures, treatments, and so on.

A nurse speaking in support of the best interest of a vulnerable client reflects which nurse's duty? Caring Veracity Advocacy Confidentiality

Advocacy Rationale The nurse has a professional duty to advocate for a client by promoting what is best for the client. This is accomplished by ensuring that the client's needs are met and by protecting the client's rights. Caring is a behavioral characteristic of the nurse. Veracity relates to the habitual observance of truth, fact, and accuracy. Confidentiality is an ethical principle and legal right that the nurse will hold secret all information relating to the client unless the client gives consent to permit disclosure.

A client is discharged home the same day as a hernia repair. Where did the operation likely take place? Long-term care center Hospice service center Ambulatory surgery center Specialty home care service center

Ambulatory surgery center Rationale Outpatient hernia repair is performed in an ambulatory surgery center. The primary goal of a long-term care facility is to provide prolonged care for the clients with chronic illnesses and physical impairments, but that would not apply to a client with a simple hernia repair. Hospice service provides palliative care to terminally ill clients. Specialty home care service centers provide care for pediatric, psychiatric, and terminally ill clients in their homes.

In which phase does cell division begin? Prophase Anaphase Telophase Metaphase

Anaphase Rationale In anaphase, the cell starts dividing. In prophase, the formation of chromatids and spindle fibers occurs. In telophase, the two nuclei appear, and the chromosomes disperse. In metaphase, the nuclear membrane and nucleolus disappear.

What should a nurse recommend to help a client best during the period immediately after a spouse's death? Crisis counseling Family counseling Marital counseling Bereavement counseling

Bareavement counceling Rationale Bereavement counseling involves being a part of a group of people who also have sustained a loss; members provide support to each other. Individual counseling will not provide the support that a group provides; group counseling may last longer than crisis intervention. The information provided did not indicate other family members. Marital counseling involves both a husband and a wife.

A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider? Personality traits Educational level Cultural background Past experiences with death

Cultural Background Rationale In the initial stage of grief the degree of anguish experienced is influenced by cultural background. Although personality traits factor into the grief process, they are not as important as culture. Educational level is not related directly to a grief response. While past experience is important, it is not as significant as culture.

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? Exploring Reflecting Refocusing Acknowledging

Exploring Rationale Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion.

Which is the main function of a joint? Synthesis of chemicals Facilitation of movement Regulation of body temperature Production of various blood cells

Facilitation of movement Rationale Joints help facilitate movement in the body. The function of the integumentary system is to synthesize chemicals. Regulation of body temperature is the function of the integumentary system. The function of the lymphatic system is to produce various blood cells.

Which physical finding is most likely associated with child sexual abuse? Bed sores Cigarette burns Human bites on the hands Foreign bodies in the urethra

Foreign bodies in the urethra Rationale Foreign bodies in the urethra, rectum, or vagina are a strong indicator of sexual abuse of a child. Bed sores are more likely to be a sign of abuse of an older adult. Cigarette burns and human bites may appear on children, but they are more typical of intimate partner violence.

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? Soap Time Water Friction

Friction Rationale Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.

Which palliative surgical procedure involves the insertion into the stomach of a catheter that is then sutured to the abdominal wall? Gastrostomy Orchiectomy Blalock-Taussig shunt Pulmonary artery banding

Gastrostomy Rationale Gastrostomy is a palliative surgical procedure that involves the insertion into the stomach of a catheter that is then sutured to the abdominal wall. Orchiectomy is the removal of the testes. Blalock-Taussig shunt is a palliative procedure that involves the creation of an artificial connection between the pulmonary artery and the aorta. Pulmonary artery banding impedes the flow of blood from the right ventricle to the pulmonary circulation.

What is the role of a vocational rehabilitation counselor who is caring for a client in a rehabilitation center? Promotes the client's interest in activities Helps the client obtain training for new employment Assists the client in developing realistic positive attitudes Educates the client and family concerning the rehabilitation process

Helps the client obtain training for new employment Rationale The vocational rehabilitation counselor helps the client obtain training for new employment. The therapeutic recreation therapist promotes the client's interest in activities. The clinical psychologist assists the client in developing realistic positive attitudes. The rehabilitation registered nurse educates the client and family concerning the rehabilitation process.

Which two groups of American women have the highest breast and cervical cancer mortality rates? Native American and Hispanic Hispanic and African American Asian American and Native American Asian American and African American

Hispanic and African American Rationale Hispanic and African American women have the highest breast and cervical cancer mortality rates. The breast and cervical cancer mortality rates for Native American and Asian American women are lower.

Which type of continuing care should a client expect if discharged home with a drug infusion device to continue treatment for a leg wound? Home care Rehabilitation Skilled nursing care Outpatient therapy

Home care Rationale Clients who are discharged with an infusion device to continue drug therapy at home should expect home care services to teach appropriate administration of drug therapy in the client's home. The client is being discharged to the home and not to rehabilitation or to a skilled nursing facility. Outpatient therapy is not identified as a method for continuing antibiotic therapy with an infusion device.

Which intervention is used to measure axillary temperature? Instructing the client to regown Having the client assume the Sims position Being certain that the area is wet and warm Inserting a probe into the center of the axilla

Inserting a probe into the center of the axilla Rationale While measuring the axillary temperature, the nurse should insert the probe into the center of the axilla. The nurse should assist the client to regown rather than just instructing the client. The client should be in sitting, supine, or side-lying position. The axillary area should be clean and dry.

Which health care organization has recently focused on promoting the need for changes in the nursing work force? Institute of Medicine American Red Cross National Federation of Licensed Practical Nurses American Nurses Association

Institute of Medicine Rationale The Institute of Medicine recently established a focus on promoting the need for changes in the nursing work force, including the goal of 80% of working nurses to be baccalaureate degree-prepared. The American Red Cross is a volunteer organization with less of a focus on the nursing work force. The National Federation of Licensed Practical Nurses and the American Nurses Association have goals more focused on nursing education and less on the nursing work force.

Which statement is true regarding a biomedical health belief system? Many consider it a system of "third-world" beliefs and practices. It includes acupuncture, aromatic therapy, meditation, and therapeutic touch. It states that life processes can be manipulated by humans with mechanical interventions. It includes blessings from spiritual leaders, apparitions of dead relatives, and miracle cures.

It states that life processes can be manipulated by humans with mechanical interventions.

A nurse takes the rectal temperature of a client with an electronic thermometer. What should the nurse do to ease the insertion? Assist the client into Sims position Lubricate one inch of the thermometer tip Hold the electronic probe until an audible signal occurs Slide the disposable plastic cover over a thermometer probe

Lubricate one inch of the thermometer tip Rationale Lubricating one inch of the thermometer tip will ease the insertion of the instrument into the rectum. Assisting the client into Sims position will ensure the thermometer's placement. Holding the electronic probe until an audible signal occurs will ensure an accurate reading. Sliding a disposable plastic cover over the thermometer probe will help to prevent the spread of microorganisms.

The count of hydrocodone is incorrect. After several minutes of searching the medication cart and medication records, no explanation is found. Who should the primary nurse notify about the discrepancy? Nursing unit manager Hospital administrator Quality control manager Healthcare provider prescribing the medication

Nursing unit manager Rationale Controlled substance issues for a particular nursing unit are the responsibility of that unit's nurse manager. Responsibility flows directly from the staff of a nursing unit to the nurse manager; the nurse manager reports to a nurse administrator. There is no direct flow of accountability from the primary nurse to the quality control manager. Healthcare providers are responsible for medical management issues, not issues associated with management of a nursing unit.

Which act instituted significant Medicare and Medicaid requirements for documentation? The Joint Commission Omnibus Budget Reconciliation Act Department of Health and Human Services Health Insurance Portability and Accountability Act

Omnibus Budget Reconciliation Act The Omnibus Budget Reconciliation Act (OBRA) instituted significant Medicare and Medicaid requirements for documentation. The joint commission outlined the legal guidelines to be followed while documenting. Department of Health and Human Services is responsible for making access to medical records easier for the clients. The Health Insurance Portability and Accountability Act (HIPAA) is an act that affords certain protections to persons covered by health care plans.

Which type of surgery is performed for relief or reduction of intensity of disease symptoms? Ablative Palliative Constructive Reconstructive

Palliative Rationale Palliative surgery is performed for relief or reduction of intensity of disease symptoms. Ablative surgery is the excision or removal of a diseased body part. Constructive surgery is performed to restore body functions that are lost or reduced as a result of congenital anomalies. Reconstructive surgery is performed to restore function or appearance to traumatized or malfunctioning tissue.

Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? Select all that apply. Paramedics Unlicensed assistive personnel Nurses appointed to a field team A physician who survives the incident Community response team members

Paramedics Nurses appointed to a field team Rationale Paramedics and nurses appointed to a field team are the EMS first responders who can perform triage during a mass casualty incident. Unlicensed assistive personnel can assist with providing client care in a hospital setting under the direction of a licensed practitioner. A physician who survives the incident can assist with treatment; however, this individual is not necessarily trained for triage. Community response team members can assist first responders; however, these individuals are not trained for triage.

What is the role of a hospice volunteer on a primary hospice team? Administering personal care Assisting the client with bathing Assessing the bereaved survivor Providing companionship to clients and caregivers

Providing companionship to clients and caregivers Rationale A hospice volunteer provides companionship to clients and caregivers. A hospice aide helps with personal care and assists the client with bathing. A bereavement coordinator assesses bereaved survivors.

An individual is verbally inflicting anguish, emotional pain, and distress on an older adult. Which type of abuse is this? Sexual Physical Material Psychological

Psychological Rationale Psychological or emotional abuse involves the infliction of anguish, emotional pain, or distress through verbal or nonverbal acts. Sexual abuse is nonconsensual sexual contact including with someone who is incapable of giving consent. Physical abuse involves the use of physical force that may cause bodily injury, physical pain, or impairment. Material abuse is defined as illegal or improper exploitation of an older adult's funds, property, or other assets.

How would a home health agency governed by volunteer board representatives be classified? Public nonprofit freestanding Private for-profit freestanding Private for-profit institution-based Private nonprofit institution-based

Public nonprofit freestanding Rationale Official health agencies such as state health departments, county health departments, and city health departments are governed by volunteer boards of representatives. These are considered public nonprofit freestanding organizations. A proprietary home health agency is classified as private for-profit freestanding. A hospital-based home agency is considered private and institution-based; it may be a profit-based or nonprofit-based agency.

Which professionals in a healthcare organization can be delegators? Assistants Technicians Registered nurses Client care associates

Registered nurses Rationale Registered nurses are professionals in a healthcare organization who can be delegators. The registered nurses allocate a portion of work related to client care to other individuals. Assistants, technicians, and client care associates in a healthcare organization can be delegatees.

A nurse delegates tasks to a hospital rescue team to provide care to a group of clients who survived an earthquake. Which type of leadership is reflected in the nurse's action? Autocratic Situational Democratic Laissez-faire

Situational Rationale During autocratic leadership, the leader retains authority and responsibility. An autocratic leader places little trust and confidence in others during a natural disaster. Situational leadership requires flexibility on the part of the manager in adapting to the needs of the work group. Democratic leadership involves treating every staff member equally; this type of leadership is not appropriate in a crisis situation. Laissez-faire leadership involves delegating decision-making to the group.

A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link? Social Physical Materialistic Environmental

Social Rationale Without some form of communication there can be no socialization. People interact with other social beings, not with inanimate objects. Physical, materialistic, and environmental surroundings are all inanimate and cannot interact.

A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting of impending death? The client is revising the client's will and planning a visit to a friend The client is alternately crying and talking openly about death The client is getting second, third, and fourth medical opinions The client is refusing to follow treatments and stating they won't help anyway

The client is revising the client's will and planning a visit to a friend Rationale Revising the will and planning a visit to a friend are realistic, productive, and constructive ways of using this time. Crying and talking openly about death are signs of depression. Going from health care provider to health care provider demonstrates disbelief, denial, or desperation. Refusing to follow treatments and stating that the client is going to die anyway indicates anger and hopelessness, not acceptance.

Which is a characteristic of an autocratic leader? The leader allows two-way communication. The leader shows complete trust in the employees. The leader assigns clear and defined tasks to the group. The leader allows the employees to show their creativity.

The leader assigns clear and defined tasks to the group. Rationale An autocratic leader assigns clear and defined tasks to the group. Autocratic leadership involves one-way communication. This leader has little trust in his or her employees and does not allow employees to show their creativity

Which type of insurance provider pays for limited home care services? Medicare Medicaid Third-party insurers Prospective payment system

Third-party insurers Rationale Third-party insurers pay for limited home care services, but these services may vary with coverage; requirements, and payment rates vary. The Medicare insurance program covers disabled people, clients with end-stage renal disease, and elderly people who are older than 65 years of age. The Medicaid insurance program covers low-income clients. The prospective payment system produces incentives for home health providers to be more efficient in the delivery of home health services.

What is the goal of the American Hospital Association (AHA) with respect to clients' rights? To provide federal funding to institutions To protect the confidentiality of clients' health information To maintain written policies and procedures regarding advance directives To promote clients' knowledge regarding their rights as consumers of health care

To promote clients' knowledge regarding their rights as consumers of health care Rationale One goal of the American Hospital Association (AHA) is to promote clients' understanding of their rights and responsibilities as consumers of health care. The AHA does not provide federal funding. The Health Insurance Portability and Accountability Act states that it is the duty of the health care provider, not the AHA, to protect the confidentiality of client health information. The Patient Self-Determination Act states that institutions providing health care, not the AHA, should maintain written policies and procedures regarding advance directives.

What is the goal of a rehabilitation organization? To control and restore the client's behavior To restore the client's level of functioning To support the client who lacks the ability for self-care To provide intermediate levels of care after discharge

To restore the client's level of functioning Rationale Rehabilitation centers focus on restoring a client's psychological, social, and physical functioning. The goal of a psychiatric organization is to control and restore a client's behavior. Long-term care facilities focus care on the client who is unable to manage self-care. Transitional and subacute facilities provide intermediate levels of care to the client upon discharge from the hospital.

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the appropriate first nursing action? Turn and reposition the client every 2 hours. Cover the ulcer with an occlusive transparent dressing. Clean the ulcer with hydrogen peroxide and leave it open to the air. Provide the client with a diet high in vitamin C, zinc, and protein

Turn and reposition the client every 2 hours. Rationale Turning and repositioning immobile clients at least every 2 hours is the best initial nursing action for preventing further skin breakdown. Other measures should also be taken to relieve pressure on the area to prevent progression and promote healing. Covering the area with an occlusive transparent dressing or cleansing the area with hydrogen peroxide are not recommended for this situation. Providing a diet high in vitamin C, zinc, and protein will also aid in tissue healing and help prevent further breakdown but is not the priority action.

According to Quality and Safety Education (QSEN), what is patient-centered care? Understanding that the client is the source of control when providing care Functioning effectively within nursing and interprofessional teams to deliver quality care Using data to evaluate outcomes of care processes and designing methods to improve health care Minimizing the risk of harm to clients and health care workers through improved professional performance

Understanding that the client is the source of control when providing care Rationale The Quality and Safety Education (QSEN) competency called patient-centered care requires the nurse to understand that the client is the source of control. The nurse should therefore respect the values, beliefs, and preferences of the client to provide quality care. The QSEN competency called teamwork and collaboration states that a nurse should function effectively within nursing and interprofessional teams in order to provide quality care. Quality improvement involves using data to evaluate the outcomes of care processes and design methods to improve the health care delivery system. Safety focuses on minimizing the risk of harm to clients and health care workers through improved professional performance

Which religion involves three modes of baptism? Disciples of Christ Jehovah's Witness Unification Church United Church of Christ

United Church of Christ Rationale The United Church of Christ practices infant and adult baptism, which may include three modes: pouring, sprinkling, and immersion. Disciples of Christ and Jehovah's Witnesses baptize adults via immersion. The Unification Church does not baptize its members.

Which systems regulate acid-base balance? Select all that apply. Urinary system Digestive system Lymphatic system Respiratory system Cardiovascular system

Urinary system Respiratory system Rationale The urinary and respiratory systems are involved in acid-base balance. The digestive system is involved in absorption of nutrients. The lymphatic system is involved in protection. The cardiovascular system is involved in moving essential elements throughout the body.

Who governs an official home health agency? A paid board of directors A hospital board of directors A community-based board of directors Volunteer board representatives from the area

Volunteer board representatives from the area Rationale Volunteer board representatives from the area govern an official home health agency along with a local unit of government. Paid boards of directors govern proprietary home health agencies. A hospital board of directors governs a hospital-based home health agency. A community-based board of directors governs a voluntary home health agency.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk? Eggs Yogurt Potatoes Applesauce

Yogurt Rationale Yogurt, which contains calcium, is digested more easily because it contains the enzyme lactase, which breaks down milk sugar. Yogurt contains approximately 274 to 415 mg of calcium for an 8-oz container, depending on how it is prepared. Eggs contain approximately 22 mg of calcium. One potato contains approximately 7 to 20 mg of calcium, depending on how it is prepared. Eight ounces of applesauce contain approximately 3 mg of calcium.

Which organization established the first school for nursing education? National League for Nursing Young Women's Christian Association National Federation of Licensed Practical Nurses National Association for Practical Nurse Education and Service

Young Women's Christian Association Rationale The Young Women's Christian Association (YWCA) established the first school for nursing in Brooklyn, New York. The National League for Nursing (NLN), the National Federation of Licensed Practical Nurses (NFLPN), and the National Association for Practical Nurse Education and Service (NAPNES) are all involved in the evolution of nursing education though they are not responsible for this milestone.

Which statement is true regarding private pay? Private pay is a prepaid health plan. Private pay provides benefits for clients who are 65 or older. Private pay requires Medicare certification. Private pay involves payment directly from individuals.

private pay involves payment directly from the individual Rationale Private pay involves payment directly from individuals for home health services. Preferred provider organizations provide a prepaid health plan. Medicare provides benefits for clients who are 65 or older. Private pay does not require Medicare certification. Participation in Medicaid programs requires Medicare certification in many states.

Which therapy may be used as a palliative measure to decrease tumor mass and temporarily relieve obstruction in clients with stomach cancer? Oxygen therapy Radiation therapy Photochemotherapy Combination of chemotherapy and radiation therapy

Radiation therapy Rationale Radiation therapy may be used as a palliative measure to decrease tumor mass and temporarily relieve obstruction in clients with stomach cancer. A combination of chemotherapy and radiation therapy is sometimes used in clients who are at high risk for disease recurrence after surgery for stomach cancer. Oxygen therapy is used in the management of low oxygen levels. Photochemotherapy is used in the management of psoriasis.

After measuring the body temperature, the nurse documents a core temperature reading of 99 °F, but the actual oral route reading is 99 °F. Which route was used by the nurse for temperature measurement? Rectal Axillary Temporal Tympanic

Rectal Rationale The temperature reading through the rectal route is 1 °F greater than the oral route. The nurse most likely took a rectal reading. Axillary temperature tends to be 1 °F less than the oral temperature. The temperature readings through the temporal and tympanic route are consistent with the oral reading.

Which healthcare professional does the nurse know is authorized to delegate work to other healthcare members? Registered nurse (RN) Licensed practical nurse (LPN) Unlicensed nursing personnel (UNP) Unlicensed assistive personnel (UAP)

Registered Nurse Rationale Delegating work is the most effective professional management strategy that an RN can implement in clinical practice to improve the safety and quality of client care. RNs can delegate work to LPNs, UNP, or UAP.

How does the World Health Organization (WHO) define "health"? A condition when people are free of disease A condition of life rather than pathological state An actualization of inherent and acquired human potential A state of complete physical, mental, and social well-being

A state of complete physical, mental, and social well-being Rationale The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." All people free of disease are not healthy. For many people, health is a condition of life rather than pathological state. Life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident. Health can be seen as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others.

Which cell organelle helps in spindle formation during mitosis? Nuclei Centrioles Lysosomes Ribosomes

Centrioles Rationale During mitosis, centrioles help in spindle formation that is necessary for cell reproduction. Nuclei, lysosomes, and ribosomes are not involved in spindle formation. The nucleus is involved in cell reproduction and controls other organelles. Lysosomes help in the digestion of microbes that have invaded the cell. Ribosomes produce enzymes and other proteins.

A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse? Nurse practitioner Nurse administrator Certified nurse-midwife Clinical nurse specialist

Clinical nurse specialist Rationale The hospital will most likely hire a clinical nurse specialist. A clinical nurse specialist is an expert in a specific area of practice and in a particular setting such as an intensive care unit. A nurse practitioner has expertise in taking care of clients in an outpatient, ambulatory care, or community care setting. A nurse administrator looks after the management of the care provided to clients within a health-care agency. A certified nurse-midwife provides care to women during their pregnancy, labor or delivery.

What is the role of unlicensed assistive personnel in intravenous (IV) therapy for a client? Monitoring clinical manifestations Collecting the data to be used in the assessment of the IV site Administering IV fluids and medications Evaluating the client for clinical manifestations

Collecting the data to be used in the assessment of the IV site Rationale The role of unlicensed assistive professional in IV therapy is to collect the data that can be used in the assessment of the IV site. Monitoring clinical manifestation is performed by the licensed practical nurse (LPN). Administering IV fluids and medications is done by a registered nurse or LPN. Evaluating the client for clinical manifestations is performed by the registered nurse.

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which standard of the nursing practice as defined by the American Nurses Association does the nurse follow? Diagnosis Evaluation Assessment Implementation

Implementation Rationale The nurse will administer the tetanus as per the doctor's regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.

Which cell organelle is responsible for the digestion of microbes that have invaded the cell? Lysosomes Ribosomes Mitochondria Endoplasmic reticulum

Lysosomes Rationale Lysosomes contain enzymes that digest microbes that have invaded the cell. Ribosomes, mitochondria, and endoplasmic reticulum are not involved in the digestion of microbes. Ribosomes produce enzymes and other proteins. Mitochondria and the endoplasmic reticulum carry substances from one part of the cell to other parts of the cell.

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's initial reaction, what is the best indication that the nurse-client interaction has been therapeutic? Increased physical activity Absence of emotional outbursts Relaxation of tensed muscles Denial of the need for further discussion

Relaxation of tense muscles Rationale Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.

A client using fentanyl transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? Tell the family to remove and dispose of the patch. Leave the patch in place for the mortician to remove. Have the family return the patch to the pharmacy for disposal. Remove and dispose of the patch in an appropriate receptacle.

Remove and dispose of the patch in an appropriate receptacle. Rationale The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

In the United States, what is the professional nurse's legal responsibility regarding child abuse? Honor the request of the parents not to report the suspected abuse. Report any suspected abuse to local law enforcement authorities. Return the child to the legal parent even if he or she is suspected of abuse. Provide the parents with a copy of the child's medical record.

Report any suspected abuse to local law enforcement authorities. Rationale In all states in the United States, nurses and physicians are legally responsible for reporting suspected or actual abuse. Child protective services may obtain a court order to grant temporary guardianship if it is found that the child is in immediate danger. The other answer options do not fulfill the nurse's duty to report suspected child abuse.

Which nursing action is confidential and protected from legal action? Providing health teaching regarding family planning. Offering first aid at the scene of an automobile collision. Reporting incidents of suspected child abuse to the appropriate authorities. Administering resuscitative measures to an unconscious child pulled from a swimming pool.

Reporting incidents of suspected child abuse to the appropriate authorities. Rationale The reporting of possible child abuse is required by law, and the nurse's identity can remain confidential. The nurse is functioning in a professional capacity and therefore can be held accountable. Although the Good Samaritan Act protects health professionals, the nurse is still responsible for acting as any reasonably prudent nurse would in a similar situation.

Which staff members are part of a core interdisciplinary hospice team? Select all that apply. Social worker Medical director Hospice pharmacist Nursing coordinator Volunteer coordinator

Social worker Medical director Nursing coordinator Rationale A core interdisciplinary hospice team includes the social worker, medical director, and nursing coordinator. A hospice pharmacist and a volunteer coordinator are members of a primary hospice team.

Which statement regarding delegation is true? The task of delegation involves six rights. Delegation gives licensed personnel more time to focus on lower-level tasks. A licensed practical nurse (LPN) may not delegate ambulation of a client to a certified nursing assistant. A licensed vocational nurse (LVN) is responsible for determining the degree of assistance that a client needs.

A licensed vocational nurse (LVN) is responsible for determining the degree of assistance that a client needs. Rationale A licensed practical nurse (LPN) or licensed vocational nurse (LVN) is responsible for determining the degree of assistance needed by a client. Delegation involves five rights, not six. An LPN may indeed delegate ambulation of a client to a certified nursing assistant. Delegation gives licensed personnel more time to focus on higher-level tasks, not lower-level ones.

Which is known as the chemical messenger in the protein synthesis process? Ribosomes Lysosomes Ribonucleic acid (RNA) Deoxyribonucleic acid (DNA)

Ribonucleic acid (RNA) Rationale Ribonucleic acid is the chemical messenger. This is because the DNA encodes RNA as a message for protein synthesis and sends RNA to the ribosomes in the cytoplasm where protein synthesis occurs. Ribosomes are known as protein factories. Lysosomes are small sac-like structures that contain enzymes. Deoxyribonucleic acid is known as the chemical blueprint.

Which right is applicable when the delegator and delegatee understand a common work-related language? Right of person Right of supervision Right of circumstance Right of communication

Right of communication Rationale When the delegator and delegatee understand a common work-related language, then right communication is applicable. Right person is applicable when the delegatee has appropriate knowledge and experience to perform a task. Right supervision is applicable when the delegator is able to monitor and evaluate the client appropriately. Right circumstance is applicable when the delegation process is applicable for the situation.

What are the primary goals of most health care organizations in the 21st century? Select all that apply. Safety Teamwork Informatics Equitability Efficiency

Safety Equitability Efficiency Rationale As health care changes, safety, equitability, and efficiency have become the primary stated goals for health care organizations in the 21st century. While still important, teamwork and efficiency are not as much of a priority in the changing landscape.

Which basic human needs belongs to the fourth level as per Maslow's hierarchy of needs? Select all that apply. Self-worth Achievement Security needs Belonging needs Self-actualization

Self-worth Achievement Rationale Fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? Contact the family. Document the incident. Report the incident to the nurse manager. Escort the client to the radiology department.

Document the incident. Rationale Documenting the event on an incident report (Canada: adverse event) form provides a legal record and is critical in providing appropriate care and follow-up. Calling the family is the responsibility of the healthcare provider and nurse providing ongoing care. Reporting the incident to the nurse manager should be done, but it is not as critical as documenting the incident. Escorting the client to radiology is not the responsibility of the witnessing nurse. Once care is transferred to the emergency department nurse, it is the emergency department nurse's responsibility to arrange for or to escort the client to radiology.

Which position is appropriate for measuring rectal temperature? Sims Sitting Supine Side-lying

Sims Rationale The Sims position with upper leg flexed is appropriate for measuring rectal temperature. The sitting, supine, or side-lying positions can be used to measure oral, tympanic, or axillary temperatures.

Which statement is true regarding democratic leadership? "Democratic leadership involves the making of all decisions by the leader only." "Democratic leadership involves establishing one-way communication with the group." "Democratic leadership is primarily concerned with tasks and goal accomplishments." "Democratic leadership emphasizes team building through joint efforts of all team members."

"Democratic leadership emphasizes team building through joint efforts of all team members." Rationale Democratic leadership is a people-centered approach that emphasizes team building and collaboration through the joint effort of all team members. Autocratic style leadership involves a leader retaining all authority and responsibility. In this situation the leader establishes one-way communication with the group and is primarily concerned with goal accomplishment.

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. The nurse identifies that the UAP is providing false reassurance when the UAP makes which statement? "I agree; I think you should get a divorce." "Everything will be fine, just wait and see." "You should be glad that you have such a loving family." "In the scheme of things, you do not have a major problem."

"Everything will be fine, just wait and see." Rationale Saying that everything will be fine provides false hope. Agreeing with the client is an example of offering approval. Commenting on how a client should feel is an example of being judgmental. Implying that the problem is minor is an example of minimizing.

A nurse manager is selecting direct care nurses for a client-care project. The manager asks a direct care nurse about treatment priorities. Which answer provided by the direct care nurse would be appropriate? "I will give preference to the problems that are encountered first." "I will give preference to the problems that have the greatest urgency." "I will give preference to the problems that appear to be easiest to resolve." "I will give preference to the problems that take the shortest amount of time to resolve."

"I will give preference to the problems that have the greatest urgency." Rationale The preference for treatment should be always given to problems that have the greatest urgency such as life-threatening conditions. Secondary preference should be given to problems that are encountered first, problems that appear to be easiest to resolve, and problems that take the shortest amount of time to resolve.

Which statement is true regarding laissez-faire leadership? "Laissez-faire leadership involves completely relinquishing control." "Laissez-faire leadership requires a situation that requires an immediate decision." "Laissez-faire leadership involves establishing one-way communication with the group." "Laissez-faire leadership emphasizes team building through the joint efforts of all team members."

"Laissez-faire leadership involves completely relinquishing control." Rationale Laissez-faire leadership involves the leader completely relinquishing control. He or she chooses to avoid responsibility by delegating all decision-making to the group. In an autocratic leadership, the leader retains all authority and responsibility. He or she is primarily concerned with goal accomplishment. This leadership is important in certain situations where immediate decisions are required, and there is not enough time for group decisions. In such leadership, one-way communication with the group is established. A democratic leadership is a people-centered approach that emphasizes team building and collaboration through the joint effort of all team members.

Several recently licensed practical nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance? "If you have liability insurance, you are more likely to be sued." "Your employer provides you with the liability insurance you will need." "Liability insurance is not available for nursing professionals working in a hospital." "Personal liability insurance offers representation if the State Board of Nursing files charges against you."

"Personal liability insurance offers representation if the State Board of Nursing files charges against you." Rationale Personal liability insurance will represent a nurse before the State Board of Nursing, whereas employee liability insurance will not. A nurse can be sued whether or not the nurse has liability insurance. Employer liability insurance will represent the nurse in charges related to employment, not charges brought by the State Board of Nursing. Liability insurance is available for all nurses.

Which statement is most appropriate regarding situational leadership? "Situational leadership involves establishing one-way communication with the group." "Situational leadership is about delegating all decision-making responsibilities to the group." "Situational leadership emphasizes team building through the joint efforts of all team members." "Situational leadership is based on the flexibility of the manager in adapting to the needs of the individual."

"Situational leadership is based on the flexibility of the manager in adapting to the needs of the individual." Rationale Situational leadership is a comprehensive approach to the issue of management that takes into account the style of the leader, the group being managed, and the situation at hand. This style is based on the flexibility of the manager in adapting to the needs of the individual. In autocratic leadership, the leader retains all authority and responsibility, assigns clearly defined tasks, and establishes one-way communication with the group. In laissez-faire leadership, the leader avoids responsibility by delegating all decision making to the group. Democratic leadership is a people-centered approach that emphasizes team building and collaboration through the joint effort of all team members.

Which statement is true regarding autocratic style leadership? "This leadership style completely relinquishes control." "This leadership style allows employees to have more control." "This leadership style involves establishing one-way communication with the group." "This leadership style encourages individual participation in the decision-making process."

"This leadership style involves establishing one-way communication with the group." Rationale In autocratic style leadership, the leader retains all authority and responsibility. The leader is primarily concerned with task and goal accomplishment; he or she establishes one-way communication with the group. In laissez-faire leadership, the leader completely relinquishes control and delegates all decision-making to the group. Democratic style leadership is a people-centered approach that allows employees to have more control. The leader encourages individual participation in the decision-making process.

The health care provider prescribes 1000 mL of total parenteral nutrition to be administered in 12 hours. Based on this prescription, how many milliliters of solution should be administered per hour? 83 mL/hr 100 mL/hr 108 mL/hr 125 mL/hr

83 mL/hr Rationale 83 mL/hr is the correct calculation. 1000 mL of solution divided by 12 hours equals 83.3 mL/hr. Always round to the nearest whole number. 100 mL/hr is an incorrect calculation; it is too much solution per hour. 108 mL/hr is an incorrect calculation; it is too much solution per hour. 125 mL/hr is an incorrect calculation; it is too much solution per hour.

The nurse is monitoring a client's hemoglobin level. How does the amount of hemoglobin in the blood affect oxygenation? Except with rare blood disorders, hemoglobin seldom affects oxygenation status. There are many other factors that impact oxygenation status more than hemoglobin does. A low hemoglobin level causes reduced oxygen-carrying capacity. Hemoglobin reflects the body's clotting ability and may or may not impact oxygenation status

A low hemoglobin level causes reduced oxygen-carrying capacity. Rationale Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. Higher levels of hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. Hemoglobin does not affect clotting ability.

Which belief is true regarding birth control and abortion for Jewish clients? Vasectomy is preferred. Abortion is allowed when the mother's life is in danger. The use of condoms is encouraged to control the birth rate. The use of medical contraceptives is allowed to control the birth rate.

Abortion is allowed if the mother's life is in danger Rationale Judaism allows abortion if the life of the mother is in danger. Vasectomy is strictly prohibited in Judaism. The use of artificial means of birth control methods such as condoms and contraceptives are not encouraged in Judaism.

In nursing education, which health care organization-run process signifies that a program has met a higher set of standards? Approval Articulation Accreditation Advancement

Accredidation Rationale Accreditation is the process by which a health care organization decides whether a program has met a higher set of standards. Advancement is a process by which an individual nurse may choose to build his or her career. Articulation allows programs to build their curricula collaboratively, allowing one program to be the foundation for another. Approval is the process by which a program has established that it has met the state's minimum baseline standards.

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion? Speaking aloud at weekly meetings Promising to attend at least 12 meetings yearly Maintaining controlled drinking after six months Acknowledging an inability to control the problem

Acknowledging an inability to control the problem Rationale A major premise of AA is that to be successful in achieving sobriety, clients with alcohol abuse problems must acknowledge their inability to control their drinking. There are no rules about speaking at meetings, although members are encouraged strongly to do so. There are no rules of attendance at meetings, although members are encouraged strongly to attend as often as possible. Maintaining controlled drinking after six months is not part of AA; this group strongly supports total abstinence for life.

In DARE charting format, which word represents the combination of planning and implementation? Data Action Response Education

Action Rationale In DARE (Data, Action, Response and evaluation, Education and patient teaching), "action" is a combination of planning and implementing. "Data" is both subjective and objective and is equivalent to the assessment step of the nursing process. "Response and evaluation" of the client is the same as evaluation of effectiveness. "Education and patient teaching" refers to providing educational material to the client or more advanced instruction.

A nurse is caring for a client with renal failure. The client wants to go back home but the family members want the client to undergo a kidney transplant. The nurse gives details about the possible threats and benefits of the surgery to the family and informs them that the client wants to stay home. What role does the nurse play here? Educator Manager Caregiver Advocate

Advocate Rationale The nurse in the given scenario plays the role of an advocate by protecting the client's human and legal rights and by providing assistance in asserting these rights. As an educator, the nurse explains concepts and facts about health and the reason for routine care activities, demonstrates procedures, and evaluates the client's progress in learning. As a caregiver, the nurse helps clients to maintain and regain health, manages diseases and symptoms, and attains a maximal level function and independence through the healing process. As a manager, the nurse coordinates the activities of members of the nursing staff in delivering nursing care and has responsibility for personnel, policy, and budgetary issues for a specific nursing unit or agency.

Which of the following are features of a transdisciplinary rehabilitation team? Select all that apply. Relies solely on communication for success Collaborates to identify individual goals of different disciplines Allows for the blurring of boundaries between different disciplines Has discipline-specific goals and clear boundaries between disciplines Uses cross-training and flexibility to minimize the duplication of effort toward individual goal attainment

Allows for the blurring of boundaries between different disciplines Uses cross-training and flexibility to minimize the duplication of effort toward individual goal attainment Rationale A transdisciplinary rehabilitation team is distinguished from multidisciplinary-model and interdisciplinary-model teams by their blurring of boundaries between different disciplines. This type of team also uses cross-training and has flexibility to minimize the duplication of effort toward individual goal attainment. While communication is important for team members to have success, their cross-training and overlapping of boundaries allow them not to have to rely on it solely. The interdisciplinary rehabilitation team, not the transdisciplinary team, collaborates to identify individual goals of different disciplines with a problem solving approach.

Which health belief system most views the mind and body as a whole unit? Folk health Holistic health Alternative or complementary Biomedical health

Alternative or complementary Rationale An alternative or complementary system believes that the mind and body make up a whole unit and approaches treatment methods based on that. The folk health belief system considers disease as natural or unnatural and having to do with what a god or other supernatural force intends. The holistic health belief system considers both the internal and external worlds. The biomedical health belief system is scientific and searches for a disease's specific cause, onset, course, and treatment.

Which health belief system addresses the whole client by viewing symptoms as the tip of the iceberg and as the body's means of communicating to the mind? Folk health belief system Holistic health belief system Biomedical health belief system Alternative or complementary belief system

Alternative or complementary belief system Rationale An alternative or complementary belief system addresses the whole client by viewing symptoms as the tip of the iceberg and as the body's means of communicating to the mind that something needs to be changed, removed, or added to one's life. Treatment in the folk health belief system involves carrying out rituals or repentance. Treatment in the holistic health belief system is designed to restore balance with the physical, social, and metaphysical worlds. Treatment in the biomedical health belief system is focused on the use of physical and chemical interventions.

The health care provider suggests a client be admitted to a long-term care facility. Which organization developed a document that provides clarity regarding the needs and rights of this client? American Nurses Association American Hospital Association National League for Nursing Department of Practical Nursing Programs

American Hospital Association Rationale The American Hospital Association developed the Resident's Bill of Rights, a document that was developed to provide clarity regarding the needs and rights of the individual who is residing in a long-term care environment. The American Nurses Association, National League for Nursing, and the Department of Practical Nursing Programs have developed other stances and documents related to nursing and client care.

Which organization issued the Patient's Bill of Rights? Institute of Medicine (IOM) National Federation of Licensed Practical Nurses (NFLPN) American Hospital Association (AHA) National Association of Practical Nurse Education (NAPNE)

American Hospital Association (AHA) Rationale The American Hospital Association issued the Patient's Bill of Rights. While also concerned with client care, the Institute of Medicine, National Federation of Licensed Practical Nurses, and National Association of Practical Nurse Education have issued other stances and documents regarding other aspects of health care.

Which statement regarding leadership is true? Successful organizations mostly require leadership. The democratic style is useful in times of natural disaster. The most commonly used style of leadership is situational. An autocratic leader stresses prompt and orderly performance.

An autocratic leader stresses prompt and orderly performance. Rationale An autocratic leader retains all authority and responsibility and stresses prompt and orderly performance of tasks. Successful organizations require both leadership and management. The autocratic leader is useful in times of natural disaster. The most commonly used styles of leadership are autocratic, democratic, and laissez-faire.

What are the signs of elevated body temperature? Select all that apply. Dry skin Anorexia Glassy eyes Decreased pulse Elevated respiratory rate

Anorexia Glassy eyes Elevated respiratory rate Rationale Anorexia, glassy eyes, and elevated respiratory rate along with warm skin and elevated pulse rate are the signs of elevated body temperature.

Which therapies may be considered palliative in the end stage of HIV disease? Select all that apply. Antibiotics Blood transfusions Intravenous therapy Photochemotherapy Monoclonal antibody therapy

Antibiotics Blood transfusions Intravenous therapy Rationale Antibiotic use, blood transfusions, and intravenous therapy help keep clients with HIV disease comfortable and help maintain quality of life; therefore they may be considered palliative in the end stage of HIV disease. Photochemotherapy is used for the management of psoriasis. Monoclonal antibody therapy may be used to treat metastatic breast cancer in women who overexpress a breast cancer cell antigen called HER2.

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? Skin breakdown Aspiration pneumonia Retention ileus Profuse diarrhea

Aspiration pneumonia Rationale Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying semi-Fowler's or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.

A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake? Diagnosis Evaluation Assessment Implementation

Assessment Rationale The documentation of the client's information is part of an assessment. The nurse will collect all the relevant medical data of the client to help the doctor understand the client's history a make an accurate diagnosis. During diagnosis, the collected data is analyzed to find out the client's problems or issues. Evaluation is the process to see if the expected outcomes of the treatment are achieved or not. Before an evaluation, a plan is made to solve all the client's problems and then the plan is implemented.

A nurse is caring for a client with pain after surgery. The nurse takes the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. The nurse then notifies the primary healthcare provider. Which standard of practice does the nurse perform? Planning Diagnosis Assessment Implementation

Assessment Rationale When a nurse collects comprehensive data relevant to the client's health or the situation, it is considered assessment. In the given scenario, the nurse is assessing the client to minimize pain. Planning refers to instances when a nurse develops a plan to attain expected outcomes. Diagnosis refers to instances when the nurse analyzes the assessment data to determine the diagnoses or issues. Implementation refers to instances when the nurse implements the identified plan.

Which health care organization was renamed the National Association of Practical Nurse Education (NAPNE) in 1942? American Nurses Association National League for Nursing Education Association of Practical Nurse Schools National Federation of Licensed Practical Nurses

Association of Practical Nurse Schools Rationale The Association of Practical Nurse Schools, founded in 1941, was renamed the National Association of Practical Nurse Education (NAPNE) in 1942. The American Nurses Association retains its name today. The American Society of Superintendents of Training Schools was renamed the National League for Nursing Education. Like the American Nurses Association, the National Federation of Licensed Practical Nurses also retains its name today.

Which condition is associated with unevenly curved surfaces of the client's cornea? Myopia Hyperopia Emmetropia Astigmatism

Astigmatism Rationale Astigmatism is a refractive error caused by unevenly curved surfaces on or in the eye, especially of the cornea. These uneven surfaces distort vision. Myopia (nearsightedness) occurs when the eye overbends the light, and images converge in front of the retina. Hyperopia (farsightedness) occurs when the eye does not refract light enough; as a result, images actually converge behind the retina. Emmetropia is the perfect refraction of the eye, in which light rays from a distant source are focused into a sharp image on the retina.

Which type of leadership gives all authority and responsibility of tasks and goal accomplishment to a leader? Autocratic leadership Situational leadership Democratic leadership Laissez-faire leadership

Autocratic leadership Rationale In an autocratic leadership, decisions are made only by the leader.

A primary healthcare provider notes that all conventional treatment procedures have proved to be ineffective in managing a client's disorder. The primary healthcare provider decides to try an experimental treatment. The nurse ensures that the client has understood the implications of the new treatment plan thoroughly and then signs the client's consent form as a witness. Which basic healthcare ethic does the nurse follow in this situation? Justice Autonomy Beneficence Nonmaleficence

Autonomy Rationale Autonomy refers to the commitment to include clients in decisions about all aspects of care as a way of acknowledging and protecting their independence. In the given situation, the nurse ensures that the client has thoroughly understood the new treatment plan before gaining written consent. This ensures that the client is involved in the decision-making process appropriately. Justice refers to fairness. The given situation does not deal with fairness. Beneficence refers to taking positive actions to help others. This involves keeping the interests of the client before self-interest. Nonmaleficence is the avoidance of harm or hurt. Weighing the pros and cons of the new treatment plan would involve nonmaleficence.

Which palliative procedure involves the creation of an artificial connection between the pulmonary artery and the aorta? Gastrostomy Orchiectomy Blalock-Taussig shunt Pulmonary artery banding

Blalock-Taussig shunt Rationale Blalock-Taussig shunt is a palliative procedure that involves the creation of an artificial connection between the pulmonary artery and the aorta. Orchiectomy is the removal of the testes. Gastrostomy involves insertion into the stomach of a catheter that is then sutured to the abdominal wall. Pulmonary artery banding impedes the flow of blood from the right ventricle to the pulmonary circulation.

What is the first strategy for burnout prevention that deliberately reflects on the nurse's stress? Focus Choice Balance Awareness

Awareness Rationale Awareness is the first strategy of burnout prevention because it deliberately reflects on the stress in one's life. Focusing on the goals to be achieved with full energy and the ability to make choices and prioritize are helpful, but these are not the first strategies. The important step next to awareness is to prevent or deal with burnout for restoring balance in one's life.

Which act enacted by the United States Congress imposed new limits on home health care payments? Social Security Act (SSA) Balanced Budget Act (BBA) Prospective Payment System (PPS) Health Care Financing Administration (HCFA)

Balanced budget Act (BBA) Rationale Congress imposed new limits on home health care payments through a provision of the Balanced Budget Act of 1997 (BBA) in an effort to control home health expenditures. The Social Security Act includes two enactments (Medicare and Medicaid) that directly impact how home health care provides health care to members for a fixed prepaid rate. The Prospective Payment System Act (PPS) was enacted by Congress as a part of the Tax Equity and Fiscal Responsibility Act for hospitals receiving Medicare reimbursement. The Health Care Financing Administration (HCFA) implemented a new payment system for home health agencies to increase payment to clients.

The hospital's policy requires two nurses to supervise the wasting of excess opioid solutions. The nurse draws up the prescribed dose and then requests that another nurse witness wasting of the remaining medication. The second nurse states that there is no time to observe the wasting of the medication, enters the identification to serve as the witness, and leaves the area. What is the appropriate action for the first nurse to take? Waste the appropriate amount of medication and administer the appropriate dose to the client. Accept the second nurse's identification as the witness but ask another nurse to observe the actual wasting. Cancel the process and ask another nurse to serve as the witness and to observe the wasting of the medication. Insist that the second nurse re-enter the area to actually observe the wasting of the medication.

Cancel the process and ask another nurse to serve as the witness and to observe the wasting of the medication. Rationale According to hospital policy the wasting of the excess opioid solution must be monitored by two nurses. This provides for client safety and protects the nurse legally. It is unsafe for the first nurse to proceed without a second nurse performing observation and documentation. Asking another nurse to observe the wasting of the excess solution but not to serve as the documented witness is a violation of the policy. Documenting something that was not performed is unethical. Insisting that the second nurse interrupt another pressing responsibility may result in jeopardizing another client.

The rehabilitation team members on a hospice unit are caring for a client. One of the team members provides spiritual guidance to the client. Which team member plays this role? Chaplain Clinical psychologist Speech-language pathologist Vocational rehabilitation counselor

Chaplain Rationale A chaplain plays the role of a spiritual consultant, providing spiritual support and guidance to clients. A clinical psychologist plays the role of an emotional evaluator by assessing the client's disposition on the mental health continuum. A speech-language pathologist is responsible for designing the rehabilitation communication program and for helping the client to regain communication skills. A vocational rehabilitation counselor plays the role of a vocational planner, helping the client obtain training for current employment.

Who acts as a delegator in the absence of the registered nurse? Charge nurse Patient care associate Licensed practical nurse Unlicensed nursing personnel

Charge Nurse Rationale The charge nurses act as a delegator on the basis of knowledge and experience in clinical settings. In the absence of a registered nurse, the charge nurse usually delegates the tasks. A patient care associate assists and monitors vital signs. Licensed practical nurses and unlicensed nursing personnel are considered delegatees due to insufficient experience and training.

While caring for a client with schizophrenia, a nurse understands that psychotherapy is against the client's religious beliefs. To which religious community does the client likely belong? Mormon Christian Science Disciples of Christ Assemblies of God

Christian Science Rationale The Christian Science community is against certain therapies including psychotherapy. The Mormon, Disciples of Christ, and Assemblies of God communities do not prohibit psychotherapy.

Which religious group may refuse autopsy? Baptist Mormon Christian Science Church of the Brethren

Christian Science Rationale Families of Christian Science clients may refuse an autopsy due to their beliefs. Baptists, Mormons, and Christian Science clients are less likely to be opposed to it.

Which religious community seeks exemption from vaccinations? Islam Christian Science Eastern Orthodox Assemblies of God (Pentecostal)

Christian Science Rationale The Christian Science community is against vaccinations unless they are legally compulsory. The Islam, Eastern Orthodox, and Pentecostal communities allow vaccinations.

Which characteristics would a holistic health belief system exhibit? Select all that apply. Circumcision is considered a religious practice. Rituals and repentance comprise treatment. Animate or inanimate objects may have healing powers. Physical and chemical interventions comprise treatment. Humans can manipulate life processes with mechanical interventions.

Circumcision is considered a religious practice Animate or inanimate objects may have healing powers Rationale In a holistic health belief system, religious experiences are based on cultural beliefs. Therefore, a ritual like circumcision is viewed as a religious, not medical, practice, and animate or inanimate objects may have healing powers. In a folk health belief system, not a holistic one, treatment involves rituals and repentance. In a biomedical health belief system, not a holistic one, physical and chemical interventions comprise treatment, and humans can manipulate life processes with mechanical interventions.

The nurse is caring for four clients on a medical unit. Which client should the nurse see first? Client with anemia Client with chest pain Client with pneumonia Client with cough and cold

Client with chest pain Rationale Clients with chest pain have a life-threatening condition that requires immediate intervention. Clients with anemia may not require immediate attention because it is not a life-threatening problem. A client with pneumonia is included in urgent triage, which indicates that the client may have delayed treatment. A client with a cough and cold can wait for some time before receiving care.

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? Cognitive response Emotional response Perceptual response Physical response

Cognitive response Rationale Clients experiencing a cognitive response exhibit an inability to control the direction of thought content, attention span, and concentration. Clients also experience difficulty with memory, problem solving, and task performance. Clients exhibiting an emotional response exhibit inappropriate emotional responses, such as apathy, anxiety, fear, anger, belligerence, panic, and/or depression. Clients may also experience rapid mood changes. Perceptual response is the inaccurate perception of sights, sounds, tastes, smells, body position, coordination, and equilibrium. Decreased attention span and concentration does not fall within the physical response; they fall within the cognitive response.

Which procedures are examples of palliative surgery? Select all that apply. Colostomy Repair of cleft palate Replacement of cornea Replacement of kidney Debridement of necrotic tissue

Colostomy Debridement Rationale Colostomy and debridement of necrotic tissue are examples of palliative surgery. Repair of cleft palate is an example of constructive surgery. Replacement of a cornea or kidney is an example of transplant surgery.

Which statement is true about compartmentalizing? Compartmentalizing deliberately reflects on the stressor. Compartmentalizing means paying attention to one's own personal needs. Compartmentalizing is closely aligned with focusing, with an emphasis on outcome. Compartmentalizing helps the nurse to complete the job at hand as soon as possible.

Compartmentalizing helps the nurse to complete the job at hand as soon as possible Rationale Compartmentalizing is a stress management strategy that may enable the nurse to complete a job as soon as possible. It helps to manage stress by establishing boundaries on life tasks. Awareness deliberately reflects on stressors. Altruistic egoism means paying as much attention to one's own personal needs as one would to others. Goals are closely aligned with focusing, with an emphasis on the outcomes.

A nurse helps a client to clarify health problems and choose appropriate courses of action. What competency in community-based practice is the nurse exercising? Educator Caregiver Counselor Epidemiologist

Counselor Rationale When a nurse is helping a client to identify and clarify health problems and choose appropriate courses of action to solve those problems, the nurse is acting as a counselor. The nurse acts as an educator by establishing relationships with community service organizations. The nurse acts as an epidemiologist when he or she is involved in case finding, health teaching, and tracking incident rates of an illness. The nurse acts as a caregiver when he or she provides appropriate, individualized nursing care for specific clients and their families.

The nurse leader is teaching the staff that the health care provider continuously strives to work effectively within the cultural context of a client. Which cultural principle is the nurse leader explaining? Cultural diversity Cultural sensitivity Cultural imposition Cultural competence

Cultural competence Rationale Cultural competence is the process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of a client, individual, family, or community. Cultural diversity describes a vast range of cultural differences among individuals or groups. Cultural sensitivity describes the affective behaviors in individuals such as the capacity to feel, convey, and react to ideas, habits, and customs or traditions unique to a group of people. Cultural imposition is defined as the tendency of an individual or group to impose their values, beliefs, and practices on another culture for various reasons.

A nurse's co-worker approaches the nurse to inquire about the test results of a friend that is being cared for by the nurse. How should the nurse respond? Answer the questions softly so other people will not hear. Decline to discuss the friend's medical condition. Give the co-worker the name of the client's healthcare provider, so the co-worker can contact the provider instead. To provide reassurance, tell the co-worker of the friend's test results that are within normal limits.

Decline to discuss the friend's medical condition. Rationale All client health information in this situation is confidential, regardless of the relationship of the employee to the client. Therefore declining to discuss this information and suggesting visiting the client is the best response. It is especially important that answering any questions regarding the client's status or test results, including names and room number, not be discussed in public places to maintain the client's right to confidentiality. The client's physician should also follow the same procedure regarding discussion of a client.

A nurse caring for a hospitalized woman begins to suspect during assessment that the woman is experiencing domestic abuse. Which behavioral findings might lead the nurse to this suspicion? Select all that apply. Depression Suicide attempts Chronic pelvic pain Urinary tract infections Irritable bowel syndrome

Depression Suicide attempts Rationale Behavioral signs and symptoms that may indicate a woman is a victim of domestic violence include depression and suicide attempts. Chronic pelvic pain, urinary tract infections, and irritable bowel syndrome are physical, not behavioral, signs and symptoms that a woman may be experiencing domestic abuse.

A registered nurse is educating a nursing student about descriptive theories. Which point stated by the nursing student needs correction? Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories help direct specific nursing activities. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.

Descriptive theories help direct specific nursing activities Rationale Descriptive theories do not direct specific nursing activities. Instead, they help to explain client assessments. Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.

What is the definition of health disparities? Factors that help explain why some people experience poorer health than others The health of a person or community along with the many measures that contribute to this health Differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific populations Something that is achieved when every person has the opportunity to attain his or her health potential and no one is disadvantaged

Differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific populations Rationale Health disparities are the differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific populations. Determinants of health are factors that help explain why some people experience poorer health than others. Health status is the health of a person or community along with the many measures that contribute to this health. Health equity is achieved when every person has the opportunity to attain his or her health potential and no one is disadvantaged.

A nurse is reviewing a client's plan of care. Which is the determining factor in the revision of the care plan? Time available for care Validity of the problem Method for providing care Effectiveness of the interventions

Effectiveness of the interventions Rationale When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? Elevate HOB 30-45 degrees. Decrease the flow rate at night. Check for residual daily. Irrigate regularly with warm tap water.

Elevate HOB 30-45 degrees. Rationale To prevent aspiration, the nurse should keep the head of the bed elevated between 30-45 degrees. Decreasing flow rate, checking residual, and irrigating regularly will not prevent aspiration.

A nurse refuses to administer an analgesic to a young African American man with sickle cell anemia, because she believes young African American men abuse drugs. What is reflected in the nurse's action? Enculturation Ethnocentrism Cultural imposition Cultural competence

Ethnocentrism Rationale Ethnocentrism is the belief that one's own way of life is superior to that of others; this results in biases and prejudices that lead to negative associations with other groups, like that illustrated by the nurse who assumes the client would abuse analgesics. Enculturation is socialization into one's primary culture as a child. Cultural imposition is using one's own values and lifestyles as an absolute guide in dealing with clients and interpreting behavior. Cultural competence is having specific knowledge, skills, and attitudes that ensure the delivery of culturally congruent care.

What is the time period required to recertify a home care treatment plan in order for the client to continue to receive services? Every year Every 30 days Every 60 days Every 90 days

Every 60 days Rationale To receive home care benefits beyond the original 60-day period, a recertification must be completed for each subsequent 60-day period.

Which statement is true regarding home care services? Home care services are cost effective. Home care services are only for older adults. Social workers are not involved in home care services. Intravenous therapy is not included in home care services.

Home care services are cost effective Rationale Home care services are cost effective. Home health services are for all age groups. Social workers take an active role in home health care. Intravenous therapy is included in home care services.

Which statement is true about Medicaid? The monthly premium is funded by the client's paycheck. Federal and state governments are the administrators. Clients older than 65 are eligible to apply. Anyone with permanent kidney failure is eligible to apply.

Federal and state governments are the administrators

Which skills would be essential for an effective nurse manager to develop and improve collaboration with others? Select all that apply. Flexibility Reacting hastily Showing frustration Ability to listen to others Ability to share information and ideas

Flexibility Ability to listen to others Ability to share information and ideas Rationale In order to collaborate effectively, the nurse should be flexible, must be willing to listen to others, and must share information and ideas with others. The nurse manager should plan a thoughtful response, consider others' perspective first, and not react hastily. The nurse manager should not share his or her own anger or frustration with other staff.

Which surgical procedure may be performed as a palliative measure in a client with esophageal cancer? Gastrostomy Thoracotomy Blalock-Taussig shunt Pulmonary artery banding

Gastrostomy Rationale Gastrostomy is a surgical procedure that may be performed as a palliative treatment measure in a client with esophageal cancer. Thoracotomy is the surgical creation of an opening into the thoracic cavity. Blalock-Taussig shunt is a palliative procedure that is used to manage tetralogy of Fallot in infants. Pulmonary artery banding is a palliative procedure performed in infants with symptomatic ventricular septal defect.

Which organization provides health care to members for a fixed prepaid rate? American Hospital Association (AHA) Health maintenance organizations (HMOs) National Federation of Licensed Practical Nurses (NFLPN) National Association for Practical Nurse Education and Service (NAPNES)

Health maintenance organizations (HMOs) Rationale Health maintenance organizations (HMOs) provide health care to members for a fixed prepaid rate. These services include medical care, nursing care, diagnostic tests, hospitalization, and various inpatient and outpatient treatments. The American Hospital Association (AHA) is responsible for ensuring the client's fundamental rights to treatment with dignity and compassion. The National Federation of Licensed Practical Nurses (NFLPN) is responsible for addressing the needs of practical nursing education. The National Federation of Licensed Practical Nurses (NFLPN) changed its name to the National Association for Practical Nurse Education and Service (NAPNES) in 1959; this organization addresses the needs of practical nursing education.

Which statement correctly defines palliative care, according to the World Health Organization? Providing care for a client's body after death Providing adequate nutrition and maintaining elimination patterns The active, complete care of a client only in the last 6 months of life Helping patients and families deal with possibly fatal illnesses and quality-of-life issues

Helping patients and families deal with possibly fatal illnesses and quality-of-life issues Rationale According to the World Health Organization, palliative care is defined as helping patients and families deal with possibly fatal illnesses and quality-of-life issues. Postmortem care is the provision of care for a client's body after death. Physical care is the provision of adequate nutrition and maintenance of elimination patterns. Palliative care is the active, complete care of a client whose disease has not responded to curative therapy; it may be started earlier in the dying process, not only in the last 6 months of life.

Which action of the nurse ensures safety during rectal temperature measurement? Assisting the client to get in a position of comfort Holding onto the thermometer throughout the procedure Holding the electronic probe until an audible signal occurs Moving the bed linens aside to expose only the rectal area

Holding onto the thermometer throughout the procedure Rationale Holding onto the thermometer throughout the procedure will ensure the client's safety. Assisting the client to get into a position of comfort will restore the client's sense of well-being. Holding the electronic probe until an audible signal occurs will ensure accurate measurement. Moving bed linens aside to expose only the rectal area will prevent the client from being unnecessarily exposed.

Which belief system sees restoring balance in physical, social, and metaphysical worlds as the goal of treatment? Folk health Holistic health Biomedical health Alternative or complementary health

Holistic Health Rationale In a holistic health belief system, treatment aims to restore balance in the physical, social, and metaphysical worlds. In a folk health belief system, the goal of treatment is to please a supernatural force. In an alternative or complementary health belief system, a variety of nonmedical techniques like acupuncture, meditation, aromatherapy, and more may comprise treatment. In a biomedical health belief system, treatment includes physical and chemical interventions.

Which member of a primary hospice team is responsible for rendering personal care and assisting with the bathing of clients? Hospice aide Primary nurse Volunteer coordinator Bereavement coordinator

Hospice Aid Rationale A hospice aide is responsible for providing personal care to the client and assisting with bathing. A primary nurse serves as a liaison among the client, health care provider, and interdisciplinary team; evaluates the client's response to treatment; and educates the client and family on disease process and care. A volunteer coordinator assesses the needs of the client and caregiver for volunteer services. A bereavement coordinator assesses and supports the bereaved survivor and facilitates support groups.

Which type of home care agency uses fees from all sources? Official Hospital Proprietary Combination

Hospital Rationale A hospital-based home health agency receives fees from all sources. An official home health agency receives fees from limited sources: state, local, or county revenues; grants; and/or support from charitable contributions. A proprietary home health agency receives fees from most sources, but may or may not participate in Medicare-Medicaid. A combination home health agency receives support and fees from limited sources: state, local, or county revenues; grants; and/or support from charitable contributions.

Which is the facility-level organizational model for disaster management? Medical Reserve Corps (MRC) Disaster Medical Assistance Team (DMAT) Hospital Incident Command System (HICS) National Incident Management System (NIMS)

Hospital Incident Command System (HICS) Rationale The facility-level organizational model for disaster management is the Hospital Incident Command System (HICS). The Medical Reserve Corps (MRC) is made up of a group of volunteer medical and public healthcare professionals who offer services to healthcare facilities or to the community during a disaster or pandemic disease outbreak. The Disaster Medical Assistance Team (DMAT) is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. The National Incident Management System (NIMS) was implemented by the Department of Homeland Security and FEMA to standardize disaster operations.

A client expresses concern about the surgical consent that the client signed. How should the nurse respond? Share the client's concern with the family Inform the health care provider of the client's concern Reassure the client that the surgery will be successful Cancel the surgery until the client feels more comfortable with the decision

Inform the health care provider of the client's concern Rationale The client's concern indicates that there is a need to explore informed consent further. Discussing the client's concern is a privacy issue; the nurse must obtain the client's consent to talk with the family. Reassuring the client that the surgery will be successful is false reassurance that does not address the client's concerns. The decision to cancel surgery is not within the scope of nursing practice.

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? Moving the client's bedside table closer to the bed Encouraging the client to take an available sedative Instructing the client to call the nurse before going to the bathroom Assisting the client to telephone home to say goodnight to the spouse

Instructing the client to call the nurse before going to the bathroom Rationale Statistics indicate that the most frequent cause of falls in hospitalized clients is getting up or attempting to get up to the bathroom unassisted. Although moving the bedside table closer to the bed is helpful in reducing falls because it moves the bedside table closer to the client's center of gravity, it is not the primary intervention to prevent falls. Sedatives contribute to the risk for falls by altering the client's sensorial abilities. Although talking to the spouse may calm the client and contribute to sleep, it does not reduce the incidence of falls.

Which system is involved in the synthesis of chemicals? Skeletal system Nervous system Muscular system Integumentary system

Integumentary system Rationale The integumentary system helps in the synthesis of chemicals. The skeletal system provides support. The nervous system helps in communication. The muscular system helps in movement.

A woman says, "Because of my religious beliefs, I want to be checked by a female primary health care provider." Later the woman says, "I'm not allowed to make decisions regarding family planning, so my husband needs to be here." To which religion does this woman likely belong? Islam Judaism Episcopal Pentecostal

Islam Rationale Muslim women consider modesty to be very important, so they prefer female health care providers to male health care providers. Women with strict Islamic values are not allowed to sign consent forms or make decisions regarding family planning; it is mandatory for the husband to make the decisions. Jewish, Episcopal, and Pentecostal women do not follow the same set of rules.

Which statement about palliative care is correct, according to the World Health Organization (WHO)? Its focus is improving and maintaining the client's quality of life as much as possible. It helps clients and families deal with potentially fatal illnesses and quality-of-life issues. Its goal is to prevent and relieve suffering of clients by quickly identifying and treating pain. Its focus is to relieve suffering through management of pain and symptoms only in clients who are in the last 4 months of life.

It helps clients and families deal with potentially fatal illnesses and quality-of-life issues. Rationale According to WHO, palliative care helps clients and families deal with possibly fatal illnesses and quality-of-life issues. WHO says that the goal of palliative care is improving and maintaining the client's quality of life as much as possible and that the focus of palliative care is preventing and relieving the suffering of clients by quickly identifying and treating pain. Palliative care is the relief of suffering through management of pain and symptoms in clients in any stage of a serious illness.

Which statement is true about home health care service? It includes shoppers, respite care workers, and nursing care staff. It is a community-funded center that provides recreational activities. It is a setting that provides structured age-appropriate activities during the day. It involves providing the caregiver with a break from responsibility.

It includes shoppers, respite care workers, and nursing care staff Rationale Home health care service includes shoppers, respite care workers, and nursing care staff. A senior center is a community-funded facility that provides recreational activities, lunch, health screening, and exercise classes. Day care is the setting that provides structured age-appropriate activities for children during the day. Respite care involves providing caregivers with a break from the responsibility of providing care.

What is the main focus of a nurse caring for a client with liver carcinoma? Promoting adequate rest Administering antiemetics as ordered Keeping the client as comfortable as possible Providing a diet high in carbohydrates and low in fats

Keeping the client as comfortable as possible Rationale The main focus of a nurse while caring for a client with liver carcinoma is keeping the client as comfortable as possible. The nurse should promote adequate rest, administer antiemetics as ordered, and provide a diet high in carbohydrates and low in fats to clients who have imbalanced nutrition resulting from hepatitis.

Which healthcare team member would the nurse expect can be delegated with the task of administering oral medication to a client per the functional model? Registered nurse Patient care associate Licensed practical nurse Unlicensed assistive personnel

Licensed practical nurse Rationale The licensed practical nurse can give oral medication to a client. The registered nurse gives IV medication to a client. Patient care associates assist and monitor vital signs. Unlicensed assistive personnel perform all hygienic tasks.

While auditing unit documents, a nurse finds some omissions. Which term best describes when the nurse meets with the staff to discuss the findings and communicates ways to achieve the desired goals? Leadership Followership Management Decision making

Management Rationale The process of guiding, planning, and controlling others in a situation where communication is shared to improve clinical processes and outcomes is referred to as management. Leadership can be defined as a process of identifying a goal or target, motivating other people to act, and providing support and motivation to achieve goals. Followership is the process of following the leader or the manager to ensure the best clinical decision making and actions taken to achieve organizational outcomes. Decision making is a process of making crucial decisions.

Which program provides a large source of revenue for a long-term care facility? Medicare Medicaid The Health Care Financing Administration (HCFA) The Occupational Safety and Health Administration (OSHA)

Medicaid Rationale Medicaid is a large source of revenue for a long-term care facility. It is a federally funded, state-operated program of medical assistance to people with low incomes. Medicare is a federally funded national health insurance program in the United States for people older than 65. The Health Care Financing Administration (HCFA) sets up guidelines for insurance programs such as Medicare to provide reimbursement services by adhering to certain guidelines. The Occupational Safety and Health Administration regulates long-term care facilities, which has led to a significant increase in the cost of health care.

Which insurance plan became effective in 1966 by an act of legislation that revolutionized home care? Medicare Medicaid Preferred provider organizations (PPOs) Health maintenance organizations (HMOs)

Medicare Rationale The Medicare insurance plan became effective in 1966 by an act of legislation that revolutionized home care. Medicaid is a federal insurance plan that pays for home care services to indigent and low-income clients of all ages. Preferred provider organizations (PPOs) and health maintenance organizations (HMOs) are prepaid health plans operated independently or through employer groups.

When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary? Volume of medication to be administered is large. Medication is irritating to subcutaneous tissue and skin. Injection site must be massaged after it is administered. Procedure requires an air bubble to be drawn into the syringe.

Medication is irritating to subcutaneous tissue and skin. Rationale The Z-track method seals the puncture at the intramuscular level, preventing seepage of injected medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin. The Z-track technique is unrelated to the volume of medication to be administered. When the volume of medication is large, it should be administered into a large muscle or divided into two syringes. Massage is avoided with the Z-track technique to help prevent the injected medication from flowing back up the needle track. Administration of a small air bubble at the completion of injection of medication into a muscle (air-lock technique) is no longer recommended because it does not increase the likelihood that medication will remain in the muscle without flowing back up the needle track.

A registered nurse has obtained a certification in Advanced Disaster Life Support training. Which organization provided this training? Hospital Incident Command System National Incident Management System National Disaster Life Support Foundation Federal Emergency Management Agency

National Disaster Life Support Foundation Rationale The National Disaster Life Support Foundation offers Core, Basic, and Advanced Disaster Life Support training courses. The courses include all essential aspects of disaster response and management. The Hospital Incident Command System (HICS) is a facility-level organizational model for disaster management, which is a part of the National Incident Management System. The Federal Emergency Management Agency (FEMA) provides numerous online resources, including Community Emergency Response Team (CERT) training to enable more self-sufficient responses to incidents and hazard situations in communities.

If there is a shortage of health care providers in the vicinity, members of which group may visit shamans for treatment? Hispanic Asian American Native American African American

Native Americans Rationale A shortage of health care providers in certain geographic areas may make it difficult for people in those areas to seek health care. Native Americans may visit shamans for treatment. Hispanic people may visit curanderos for treatment. Asian Americans may visit Chinese herbal therapists for treatment. African Americans may visit hougans for treatment.

Which type of home health agency is supported by fees from limited sources? Official Hospital Voluntary Proprietary

Official Rationale An official home health care agency is supported by fees from limited sources: state, local, or county revenues; grants; and charitable contributions. Hospital and voluntary home health agencies receive fee support from all sources. Proprietary agencies receive fees from most of the sources.

Which perspective defines home health care as a component of comprehensive health care in which individuals and their families receive services in their places of residence? Client Family Official Provider

Official Rationale Officially, home health care is defined as a component of comprehensive health care in which individuals and their families receive services in their places of residence. Viewed from the client's perspective, home health care is skilled and compassionate care provided on a one-to-one basis in the comforting and familiar surroundings of the home. Viewed from a family's perspective, home health care is a means of keeping the family together as a functioning, integrated unit. Viewed from the provider's perspective, home health care challenges all disciplines involved to provide excellent care in often less-than-excellent conditions and surroundings.

Which type of temperature measurement is contraindicated in clients with shaking chills? Oral Rectal Axillary Tympanic

Oral Rationale Oral temperature measurements are contraindicated in clients with shaking chills. Rectal temperature measurements are contraindicated in clients who have a rectal disorder, such as a tumor or hemorrhoids. Axillary temperature measurements are not contraindicated in clients with shaking chills. Tympanic temperature measurements are not contraindicated in clients with shaking chills.

Which treatment measure may be used as a palliative therapy for a client with metastatic prostate cancer? Orchiectomy Gastrostomy Blalock-Taussig shunt Pulmonary artery banding

Orchiectomy Rationale Orchiectomy may be used as a palliative therapy for a client with metastatic prostate cancer. Gastrostomy is a surgical procedure that may be performed as a palliative treatment measure in a client with esophageal cancer. Blalock-Taussig shunt is a palliative procedure that is used to manage tetralogy of Fallot in infants. Pulmonary artery banding is a palliative procedure performed in infants with symptomatic ventricular septal defect.

Which statement about palliative care needs correction? Palliative care can be started earlier in the dying process. Palliative care is aimed at improving comfort and prolonging life at all costs. Palliative care can serve as a bridge between curative care and hospice care. Palliative care is aimed at providing psychological, social, and spiritual assistance.

Palliative care is aimed at improving comfort and prolonging life at all costs. Rationale Palliative care is intended to improve comfort, not prolong life. It may be started earlier in the dying process; can serve as a bridge between curative care and hospice care; and provides psychological, social, and spiritual assistance.

The registered nurse considers the qualification of the unlicensed nursing personnel (UNP) before delegating a task. Which right of delegation is followed by the nurse? Task Person Direction Supervision

Person Rationale The knowledge and experience to perform the specific task safely by the delegatee is assessed by the qualification of the delegatee, which determines whether he or she is the right person. The right task involves assessing whether the task is legally appropriate to delegate or whether it is appropriate under institutional policies. The right direction involves the delegator providing clear and concise directions to perform the task. The right supervision is determined by whether the delegator is able to monitor and evaluate the client appropriately.

Which member of the rehabilitation team would work with the rehabilitation nurse to help the client perform the action depicted in the image? (the image shows a man holding crutches, a patient with a walker and a nurse/caregiver walking next to the patient) Chaplain Physical therapist Therapeutic recreation therapist Vocational rehabilitation counselor

Physical Therapist Rationale In the given image, the client is ambulating. The rehabilitation nurse and the physical therapist would help the client with gross motor skills like walking. The chaplain would provide spiritual support and guidance. The therapeutic recreation therapist promotes the client's interest in activities. The vocational rehabilitation counselor would help the client obtain training for new or current employment.

A client who sustained a minor hand fracture 2 months ago arrives at the physician's office for a follow-up visit and is provided with a brace. Which health care professional would help to restore the client's musculoskeletal function? Speech therapist Physical therapist Occupational therapist Clinical nurse specialist

Physical Therapist Rationale A physical therapist helps restore the client's musculoskeletal function. A speech therapist helps the client deal with disorders that affect oral communication. An occupational therapist helps the client learn to perform the activities of daily living. A clinical nurse specialist consults the nursing staff on appropriate nursing interventions to provide appropriate client care.

Which rehabilitation team member designs a client's exercise program? Physical therapist Clinical psychologist Occupational therapist Rehabilitation registered nurse

Physical Therapist Rationale A physical therapist has the role of designing an exercise program with which to perform therapy. A clinical psychologist assesses the client's mental health. An occupational therapist assesses the client's independent living needs. A rehabilitation registered nurse is the primary coordinator and educator on the team.

Which responsibility of the nurse manager differs from the responsibilities of a nurse leader? Planning the budget Motivating the team Resolving the conflicts Penalizing for poor performance

Planning the budget Rationale Budgeting is the responsibility of a nurse manager. The role of nurse leader is to motivate the nursing subordinates. Resolving conflicts is the responsibility of both the nurse leader and the nurse manager. Penalizing for poor performance is a behavior of transactional leadership.

Identify factors associated with an increased incidence of abuse within a family. Select all that apply. Acute illness Pregnancy Drug abuse Chronic illness Sexual orientation

Pregnancy Drug abuse Sexual orientation Rationale Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.

A client with a terminal disease is admitted to hospice care. The nurse coordinator assigns a primary team. Which member of the hospice team evaluates the client's response to treatment and provides emotional support to the client and his caregiver? Hospice aide Primary nurse Hospice pharmacist Bereavement coordinator

Primary nurse Rationale The primary nurse, a licensed nurse, would evaluate the client's response to treatment and provide emotional support to the client and his caregiver. The hospice aide, certified as a home health aide, is tasked with administering personal care and providing assistance with bathing. The hospice pharmacist, a licensed registered pharmacist, would provide drug consultation. The bereavement coordinator, a professional with grief experience, provides emotional support but does so for the bereaved survivor while facilitating support groups.

Which actions could be performed by a rehabilitation registered nurse (RN)? Provides physiotherapy Promotes independence Recommends equipment modifications Assists in treatment, planning, and implementation

Promotes independence Rationale A rehabilitation registered nurse (RN) promotes independence of the client. The other responsibilities belong to other rehabilitation team members. A physical therapist provides physiotherapy to promote client mobility. An occupational therapist suggests equipment modifications. A rehabilitation licensed practical nurse (LPN) assists in treatment, planning, and implementation.

Which system has majorly influenced home health care costs? Interim payment system Prospective payment system The Omnibus Budget Reconciliation Act The Health Care Financing Administration (HCFA)

Prospective payment system Rationale The prospective payment system has had a major influence on health care cost. The prospective payment system groups payments into diagnosis-related groups for Medicare and Medicaid clients. The United States Congress imposed new limits on home health payments through a provision of the Balanced Budget Act called the interim payment system (IPS). The Omnibus Budget Reconciliation Act involved the formulation of new standards for training and competency evaluation that are now in effect under Medicare training aides. The Health Care Financing Administration (HCFA) implemented a payment system for home health agencies to increase payment to clients.

Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care? Registered nurse Licensed practical nurse Primary health care provider Unlicensed nursing personnel

Registered Nurse

The rehabilitation team is caring for an older adult client, who is completely immobile, with a history of knee replacement. Which member of the team reinforces education about the processes of rehabilitation provided to the client and family members? Physical therapist Rehabilitation registered nurse Vocational rehabilitation counselor Rehabilitation licensed practical nurse/licensed registered nurse

Rehabilitation licensed practical nurse/licensed registered nurse Rationale An elderly bedridden client with a history of knee replacement may experience joint stiffness. It is a duty of a rehabilitation licensed practical nurse/licensed registered nurse to reinforce education about the processes of rehabilitation provided to the client and family members. The physical therapist provides therapy and training and assesses the client's needs. The rehabilitation registered nurse provides the education itself as well as support and also promotes independence. The vocational rehabilitation counselor helps the client find training for new or continued employment.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The health care provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? Sit down quietly next to the bed and allow her to cry. Pull the curtain and leave the room to provide privacy for the client. Explain to the client that her feelings are expected and they will pass with time. Observe the length of time the client cries and document her difficulty accepting her impending death.

Sit down quietly next to the bed and allow her to cry. Rationale Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion made without enough information.

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? Slide slowly to the floor to prevent a fall and injury. Sit on the edge of the bed while they hold the client upright. Bend forward because this will increase blood flow to the brain. Lie down quickly so the legs can be raised above the heart level.

Sit on the edge of the bed while they hold the client upright. Rationale Sitting allows the nurses to support the client until orthostatic hypotension subsides. The client's stable pulse and color indicate that the situation does not warrant placing the client in the supine position. Sliding slowly to the floor to prevent a fall and injury, bending forward, or rapid movement will permit flexion of the vertebrae, which may traumatize the spinal cord. A light-headed feeling usually is transient until the body adapts to the upright position, so leg elevation is unnecessary.

An older adult dies in the hospice care unit. A nursing coordinator delegates the task of planning for the client's funeral to one of the team members. This person is also delegated to perform all funeral services along with the family members. Which team member is this? Social worker Hospice volunteer Spiritual coordinator Bereavement coordinator

Spiritual coordinator Rationale A spiritual coordinator plans for the client's funeral and performs all funeral services along with the family members. A social worker is responsible for evaluating a client's psychosocial needs. A hospice volunteer provides companionship to the client and caregiver. A bereavement coordinator follows the plan of care for the bereaved caregiver for at least a year after the death.

What factors are most important for the nurse to consider when delegating responsibilities? Preferences of the clients and staff Physical layout of the unit and client rooms Staff member's level of education and expertise Client's diagnosis and length of time in the hospital

Stall member's level of education Rationale Delegation should provide for client safety based on staff capabilities as determined by level of education and experience. Although client and staff preferences may be considered, they are not the most important criteria for determining delegation of tasks. Although geographic factors may be considered when tasks are delegated, these are not the most significant criteria to consider. The client's acuity, not diagnosis or length of time in the hospital, is the most important client factor to consider when appropriate staff members are assigned to provide care.

Which of these is the source of support for visiting nurse associations that provide community health services? State revenues Charitable contributions Fees from limited sources Tax-deductible contributions

Tax-deductible contributions Rationale A visiting nurse association that provides community health services is a voluntary health agency. Tax-deductible contributions support such organizations. State revenues, charitable contributions, and fees from limited sources support state health departments, county health departments, and city health departments. These are all considered official health agencies.

Which act creates incentives for Medicare and Medicaid providers to improve staffing in long-term care facilities? The Omnibus Budget Reconciliation Act (OBRA) The Health Care Financing Administration (HCFA) The Patient Protection and Affordable Care Act (PPACA) The Occupational Safety and Health Administration (OSHA)

The Patient Protection and Affordable Care Act (PPACA) Rationale The Patient Protection and Affordable Care Act (PPACA) expands information about the quality of individual nursing homes on the Medicare website and creates incentives for Medicare and Medicaid providers to improve staffing. The Omnibus Budget Reconciliation Act (OBRA) defines requirements for the quality of care given to residents and covers many aspects of institutional life. The Health Care Financing Administration (HCFA) makes available information about the quality of long-term care facilities to beneficiaries, providers, researchers, and state surveyors. The Occupational Safety and Health Administration (OSHA) involves the use of long-term health care facilities and the establishment of guidelines that increase the cost of health care.

What is an example of a voluntary home health agency? City health department Visiting nurse association County health department Nursing home-based health agency

Visiting nurse association Rationale A visiting nurse association is an example of a voluntary home health agency. City health departments and county health departments are examples of official home health agencies. A nursing home-based health agency is an example of a private for-profit or nonprofit institution-based home health agency.

Which statement is most applicable to an alternative or complementary health belief system? The body and mind are seen as a whole unit. Healing powers may be ascribed to animate or inanimate objects. Disease is considered an alteration of the structure and function of the body. Treatment aims to restore balance in the physical, social, and metaphysical worlds.

The body and mind are seen as a whole unit. Rationale In an alternative or complementary belief system, the body and mind are considered a whole unit. The other statements apply primarily to other health belief systems: In a holistic belief system, healing powers may also be ascribed to animate or inanimate objects. In a biomedical health belief system, disease is an alteration of the structure and function of the body. Also in a holistic health belief system, treatment aims to restore balance in the physical, social, and metaphysical worlds

A nursing student is recalling the order of priority for giving consent to perform an autopsy in cases where a medical examiner review is not needed. Which person receives the highest priority for giving consent? Surviving child Surviving parent Surviving spouse The client in writing before death

The client in writing before death Rationale If a medical examiner's review is not necessary, the highest priority is given to the client. The client may provide the consent in writing before death. If the client or the surviving spouse is unable to give consent for the autopsy, a surviving child may be requested to give consent. The surviving parent may give consent for an autopsy if the client, the surviving spouse, and the surviving child are unable to do so. In case the client has not provided written consent before death, the nurse may obtain consent from the surviving spouse.

An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. What factor of special concern will the nurse identify when caring for this client? The client's irritability in response to deprivation The client's inecreased ability to recall recent facts The client's inability to maintain an optimal level of functioning The client's gradual memory loss resulting from change in environment

The client's inability to maintain an optimal level of functioning Rationale The onset of disabling illness will divert an older person's energies, making it difficult to maintain an optimum level of functioning. Irritability in response to deprivation is an expected response. Decreased ability to recall recent facts can result from the aging process and the change in environment; it is not as important as the loss of function. A gradual memory loss and some confusion are expected; a sudden memory loss is cause for alarm.

An interdisciplinary team of health care professionals is caring for a client with hemiplegia. Which statement about the care provided to the client is correct? The speech therapist is responsible for improving the client's oral communication. The clinical nurse specialist determines the fiber content of the food provided to the client. The physical therapist provides Instructions about the medications to be given to the client. The occupational therapist conducts counseling sessions to promote the client's well-being.

The speech therapist is responsible for improving the client's oral communication Rationale On an interdisciplinary team of health care providers, the speech therapist has the role of promoting the speech and communication skills of the client, who may have had a speech impairment caused by hemiplegia. The dietitian is responsible for determining the client's nutritional requirements. The clinical nurse specialist provides medication instructions to the client. The social worker conducts counseling sessions.

Which type of home health agency has a community-based board of directors? Official Hospital Voluntary Combination

Voluntary Rationale A voluntary home health agency has a community-based board of directors. Official home care agencies are governed by a state, county, city, or other local unit of government and volunteer board representatives from the area. A hospital-based home health agency is governed by a hospital board of directors. A combination home care agency is jointly governed by a community-based board of directors and volunteer board representatives from the area.

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. The nurse is frustrated and tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted? A system of rewards and punishment is being used to motivate the client. Leaving the client alone allows time for the nurse to think of other strategies. This behavior indicates the client's desire for solitude that the nurse is respecting. This threat is considered assault, and the nurse should not have reacted in this manner.

This threat is considered assault, and the nurse should not have reacted in this manner. Rationale This response is a threat (assault) because the nurse is attempting to put pressure on the client to speak or be left alone. This is not a reward and punishment technique that is used in behavior modification therapy. Clients in emotional crisis should not be left alone.

A nurse is caring for a hospitalized older adult. On assessment, the nurse suspects that the client is experiencing abuse. Which behavioral findings might have led the nurse to this suspicion? Verbal aggression Profound and rapid personality changes Regressed behavior Low self-esteem

Verbal aggression Rationale Of the listed behavioral findings, an abused older adult is most likely to exhibit verbal aggression. Profound and rapid personality changes and regressed behavior are more likely to be findings in abused children, and low self-esteem is more likely to be a finding in a victim of intimate partner violence.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. How should this assessment be documented? Vesicular Bronchial Crackles Rhonchi

crackles Rationale Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? "I should carry objects about 18 inches from my body." "I should sleep on my stomach with a firm mattress." "I should carry objects close to my body." "I should pull rather than push when moving heavy objects."

"I should carry objects close to my body." Rationale By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? "You will need to ask your healthcare provider; it is not part of the usual tests for people your age." "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." "It is performed routinely starting at your age as part of an assessment for colon cancer." "There must have been a positive finding after a digital rectal examination performed by your healthcare provider."

"It is performed routinely starting at your age as part of an assessment for colon cancer." Rationale The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

Which statement is true regarding the roles and responsibilities of the vocational nurse according to the American Hospital Association? "The vocational nurse is involved in supervising the newly hired registered nurse." "The vocational nurse practices only under the supervision of the nurse manager." "The vocational nurse performs actions similar to that of the registered nurse." "The vocational nurse assists in developing the role of the licensed practical nurse of the future."

"The vocational nurse assists in developing the role of the licensed practical nurse of the future." Rationale According to the American Hospital Association, the vocational nurse assists in developing the role of the licensed vocational or practical nurse of the future. The vocational nurse does not supervise the registered nurse. The vocational nurse performs activities under the supervision of a registered nurse. The vocational nurse cannot perform all of the activities that are performed by the registered nurse.

A client with terminal cancer is to receive 4 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. It is supplied at 10 mg/mL. When the client complains of severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place and leading zero if applicable. _____ mL

0.4 mL Rationale The prescribed dose is 4 mg. The available concentration is 10 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse should administer.

At 10 AM the nurse hangs a 1000-mL bag of D 5W with 20 mEq of potassium chloride to be administered at 80 mL/hr. At noon the healthcare provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion to use the circulatory access for the secondary infusion of the antibiotic? Quarter hour Half hour Three quarters of an hour 1 hour

1 hour Rationale An infusion of 1000 mL at 80 mL should take 12.5 hours. Because the primary infusion is interrupted for an hour while the antibiotic is infused, the primary bag will run an hour longer than if it were running uninterrupted. One quarter, half, and three quarters of an hour are incorrect calculations.

Which amount of time is appropriate for a nurse to spend triaging each patient during a mass casualty incident? Less than 10 seconds Less than 15 seconds Less than 30 seconds Less than 60 seconds

15 seconds Rationale Triage of victims of an emergency or a mass casualty incident (MCI) must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate.

Atenolol 150 mg by mouth is prescribed for a client with hypertension. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number. ________ tablet(s)

150mg : 50mg = 3 TABS Rationale Use the Dimensional Analysis and/or Ratio and Proportion method determine how many tablets the nurse should administer.

A healthcare provider prescribes lidocaine HCl, 1.5 mg per minute, for a client whose ECG tracing reveals multiple premature ventricular complexes (PVCs). The nurse adds 500 mg of lidocaine HCl to 100 mL of D 5W. To administer the correct amount of medication, at what rate should the nurse set the intravenous (IV) infusion pump? Record your answer using a whole number. _______ mL/hr

18 ml/hr Rationale The ordered rate is 1.5 mg/min. The available concentration is 500 mg in 100 mL. Use dimensional analysis and/or ratio and proportion to determine the appropriate rate for the infusion pump.

Which health care organization proposed in 1965 that nursing education should take place in institutions of learning within the general education system? American Nurses Association American Hospital Association Institute of Medicine Council of Practical Nursing Programs

American Nurses Association Rationale In 1965, the American Nurses Association proposed that nursing education take place in institutions of learning within the general system of education. The American Hospital Association and Institute of Medicine have focuses other than nursing education, and the Council of Practical Nursing Programs focuses on program accreditation.

Which organization's goal was to set educational standards for nurses? Frontier Nursing Service Health maintenance organization Association of Practical Nurse Schools American Society of Superintendents of Training

American Society of Superintendents of Training Rationale The primary goal of the American Society of Superintendents of Training was to set educational standards for nurses. Mary Breckenridge established the Frontier Nursing Service to deliver obstetric care to mothers in rural Kentucky. A health maintenance organization provides health care to members for a fixed prepaid rate. The Association of Practical Nurse Schools was organized to address the needs of practical nursing education.

Which health care organization was renamed the National League for Nursing Education? Frontier Nursing Service American Nurses Association Council of Practical Nursing Programs American Society of Superintendents of Training Schools

American Society of Superintendents of Training Schools Rationale The American Society of Superintendents of Training Schools was renamed the National League for Nursing Education. Mary Breckenridge established the Frontier Nursing Service to deliver obstetric care to mothers who lived in rural Kentucky. The Council of Practical Nursing Programs is an accreditation service provided by the Department of Practical Nursing Programs. The American Nurses Association is an organization with the mission of advancing and protecting the profession of nursing.

Which statements are true about practical nursing education? Select all that apply. The length of a typical practical nursing school program is 5 to 6 months. Articulation allows nursing programs to plan their curricula collaboratively. Education programs today offer various creative approaches to the education of licensed practical nurses and licensed vocational nurses. Combination of vocational/practical nursing education degrees are only available in four-year colleges. After 6 months of the first academic year, a nursing student can take the practical nurse licensure examination.

Articulation allows nursing programs to plan their curricula collaboratively. Education programs today offer various creative approaches to the education of licensed practical nurses and licensed vocational nurses. Rationale Articulation allows nursing programs to plan their curricula collaboratively. It reduces the duplication of learning experiences and supports a process of progressive buildup. Education programs today offer various creative approaches to the education of licensed practical nurses and licensed vocational nurses that involve the combination of practical and vocational nursing programs. The length of a practical nursing school program is 12 to 18 months. A combination vocational and practical nursing education with a degree is available in two-year colleges. After completion of the first academic year, not just the first 6 months, the nursing student can take the licensure examination for either practical nursing or vocational nursing.

A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent? Battery Invasion of privacy False imprisonment Defamation of character

Battery Rationale Battery is defined as intentional touching without the client's consent; this action may cause an injury or may be offensive to the client's personal dignity. Invasion of privacy is the announcement of a client's medical information to an unauthorized person. False imprisonment occurs when the nurse places the client in restraints without the approval of the primary healthcare provider. Defamation of character is the publication of false statements that result in damage to a person's reputation.

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of what? Libel Negligence Breach of confidentiality Defamation of character

Breach of confidentiality Rationale The release of information to an unauthorized person or gossiping about a client's activities constitutes a breach of confidentiality and an invasion of privacy. Libel occurs when a person writes false statements about another that may injure the individual's reputation. Negligence is a careless act of omission or commission that results in injury to another. Defamation of character is the publication of false statements that injure a person's reputation

How should nurses provide effective nursing care to clients from different cultural backgrounds? By advising clients that some cultural practices may be harmful to health By providing care that fits the clients' cultural beliefs By strictly adhering to organization policies regarding nursing care By ignoring the cultural aspect and focusing on the medical aspect of care

By providing care that fits the clients' cultural beliefs Rationale When providing care to clients from different cultural backgrounds, nurses should be careful to provide care that fits the client's cultural beliefs. It helps provide effective nursing care to the satisfaction of the client. Advising clients against their cultural practices may offend them and should be avoided. Organization policies should be made flexible to incorporate cultural aspects of care. Ignoring the cultural aspect of client care may result in ineffective nursing care.

What intervention should the nurse implement when caring for a client 24 hours postthyroidectomy? Check the back and sides of the operative site Support the head during mild range-of-motion (ROM) exercises Encourage the client to ventilate feelings about the surgery Advise the client that regular activities can be resumed immediately

Check the back and sides of the operative site Rationale Bleeding may occur, and blood will pool in the back of the neck because the blood will flow via gravity. ROM exercises will increase pain and put tension on the suture line. Talking should be avoided in the immediate postoperative period, except to assess for a change in pitch or tone, which may indicate laryngeal nerve damage. Activity should be resumed gradually and frequent rest periods encouraged.

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? Mask Clean gloves Sterile gloves Shoe covers

Clean gloves Rationale Clean gloves protect the hands and wrists from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. Masks, sterile gloves, and shoe covers are not required for this situation.

A nurse is caring for four different clients. Which client is the most likely recipient of Medicare? Client with dementia Client with depression Client with type 2 diabetes mellitus Client with permanent kidney failure

Client with permanent kidney failure Rationale Medicare is a health insurance program administered by the U.S. government as part of the Social Security Act. Based on the disorders alone, a client with permanent kidney failure is the most likely to receive Medicare. Dementia, depression, and type 2 diabetes mellitus are considered lower-priority disorders in terms of Medicare eligibility.

Which is a requirement for admission to a hospice care facility? A registered nurse's order Client's informed consent A prognosis of less than 3 months to live Diagnosis of an initial stage of the disease

Client's informed consent Rationale A client's informed consent is required for the admission into a hospice care facility. A physician's order (not a nurse's order), a diagnosis of a terminal (not initial) stage of disease, and a diagnosis of less than 6 (not 3) months to live are also required for admission to a hospice care facility.

Which process involves transferring responsibility to multiple players, usually with varying degrees of education and experience, while retaining the ultimate accountability for providing the client care? Leadership Delegation Supervision Assignment

Delegation Rationale Delegation is a process of sharing the responsibility of client care. It involves the transfer of responsibility for the performance of an activity from one individual to another, with the delegator retaining accountability for the outcome. Leadership is the use of individual traits and abilities in relationship with others, the ability to interpret the context where a situation is emerging, and entering that situation in the absence of a script or defined plan that could have been projected. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual's performance of an activity. Assignment is the transfer of both the accountability and the responsibility from one person to another.

A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with? Safety Quality improvement Patient-centered care Evidence-based practice

Evidence-based practice Rationale The QSEN competency evidence-based practice states that a nurse should integrate best current research with clinical expertise and client's preferences and values in order to provide quality healthcare. Safety involves nursing actions aimed at minimizing the risk of harm to clients and healthcare workers by ensuring system effectiveness and improving individual performance. Quality improvement involves the use of data to monitor outcomes of processes and implementation of methods to improve the healthcare delivery system. Patient-centered care states that the client is the source of control in providing healthcare.

The nurse is caring for a client who requires an intravenous infusion. The nurse explains the reason for the procedure while assembling the kit for the infusion. What is the role of the nurse in this situation? Educator Manager Advocate Caregiver

Educator Rationale The nurse assumes the role of educator when explaining to the client the need for an intravenous infusion. The nurse as a manager oversees the budget of a specific nursing unit or agency and is also responsible for coordinating the activities of the staff providing nursing care. As an advocate, the nurse protects the human and legal rights of the client. The nurse empowers the client with information required to make important health care decisions. The nurse is a caregiver when helping the client maintain and regain health, manage disease symptoms, and achieve a maximum level of functioning.

While reading an article about development of nursing in America, a nursing student learns that Mary Breckenridge established a health care service organization to deliver obstetric care to women. What is the name of this organization? American Red Cross Frontier Nursing Service National Association of Practical Nurse Education National Federation of Licensed Practical Nurses

Frontier Nursing Service Rationale Mary Breckenridge established the Frontier Nursing Service to deliver obstetric care to mothers who resided in the remote hills of Kentucky. Clara Barton established the American Red Cross in 1881. The National Association of Practical Nurse Education, originally called the Association of Practical Nurse Schools, focused on standardizing the practical nursing curriculum. Lillian Kuster established the National Federation of Licensed Practical Nurses, also focusing on nursing education as well as promoting and protecting the interests of licensed practical nurses and licensed vocational nurses.

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every four hours. Which diet should the nurse expect the health care provider to prescribe to best meet this client's immediate nutritional needs? Low in fat and vitamin D High in calories and fiber Low in residue and bland High in protein and vitamin C

High in protein and vitamin C Rationale Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.

The nurse visits a client's home twice a day to change the dressing on the client's diabetic foot. To which health care organization is the nurse most likely affiliated? Home care Hospice care Long-term care Rehabilitation care

Home Care Rationale A home care facility is one of the first organized groups to provide health education to the poor and to help people care for themselves. Visiting Nurses Association is an example of a home care agency. Hospice care agencies provide palliative care to clients. A long-term care facility is provided to the client for long-term illnesses. The aim of rehabilitation is either to restore individuals to their former level of functioning or to maintain the remaining function.

Which statement is true regarding rehabilitation services? It is provided in a variety of settings, such as personal homes. It focuses on restoring maximal possible function after illness or injury. It is required by the people of all ages who are permanently unable to function independently. It refers to a range of services that address the health, personal care, and social needs of all people.

It focuses on restoring maximal possible function after illness or injury. Rationale Rehabilitation focuses on restoring maximal possible function after illness or injury. The long-term care facility is provided in a variety of settings, such as personal homes. The long-term care facility is required by the people of all ages who are permanently unable to function independently. The long-term care facility refers to a range of services that address the health, personal care, and social needs of all people.

What is evaluation in SOAPIER? It is the effectiveness of the plan. It is the specific care given or action taken. It is the changes of the original plan of care. It is the plan of care to be given or action taken.

It is the effectiveness of the plan. Rationale Evaluation is an appraisal of the response and effectiveness of the plan in SOAPIER (Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision). Intervention or implementation is the specific care given or action taken in SOAPIER. Revision includes the changes that may be made to the original plan of care in SOAPIER. Planning includes the general statement of the plan of care to be given or action taken.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident? Exempt from any lawsuit because of the doctrine of respondeat superior Totally responsible for the obvious negligence because of failure to report defective equipment Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client Exonerated, because only the hospital, as principal employer, is responsible for the quality and maintenance of equipment

Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client Rationale Using a stretcher with worn straps is negligent; this oversight does not reflect the actions of a reasonably prudent nurse. The nurse is responsible and must ascertain the adequate functioning of equipment. The hospital shares responsibility for safe, functioning equipment.

Which health insurance program is a state-operated of medical assistance to people with low incomes? Medicaid Medicare Health Care Financing Administration Occupational Safety and Health Administration

Medicaid Rationale Medicaid is a health insurance program which is a state-operated for medical assistance to people with low incomes. Medicare is a federally funded national health insurance program for people older than age 65. Health Care Financing Administration makes available the information it obtains about quality of long-term care facilities to beneficiaries, provides, researches, and state surveyors. Occupational Safety and Health Administration guidelines ensure a safe environment for the personnel.

Which religious group is associated with women sometimes wearing head coverings during hospitalization? Lutheran Methodist Mennonite Presbyterian

Mennonite Rationale Mennonite women sometimes wear head coverings during hospitalization.

Which phase of mitosis involves the disappearance of the nuclear membrane and nucleolus? Prophase Anaphase Telophase Metaphase

Metaphase Rationale During the metaphase of mitosis, the nuclear membrane and the nucleolus disappear. During prophase the formation of chromatids and spindle fibers occurs. During anaphase cell division begins. During telophase two nuclei appear, and the chromosomes disperse.

Which organization acts as the guiding force in the development of practical nurse education? National League for Nursing Young Women's Christian Association National Federation of Licensed Practical Nurses National Association for Practical Nurse Education and Service

National Association for Practical Nurse Education and Service (NAPNES) Rationale Currently, the National Association for Practical Nurse Education and Service is regarded as the guiding force in the development of practical nursing education. Though not considered the guiding force in practical nursing education, the other organizations make contributions to nursing education as well. The National League for Nursing accredits nursing programs. The Young Women's Christian Association established the first school of practical nursing in Brooklyn, New York. The National Federation of Licensed Practical Nurses is the official membership organization for licensed practical nurses and licensed vocational nurses.

Which health care organization is limited to licensed practical nurses and licensed vocational nurses? National League for Nursing (NLN) American Red Cross National Federation of Licensed Practical Nurses (NFLPN) National Association of Practical Nurse Education (NAPNE)

National Federation of Licensed Practical Nurses (NFLPN) Rationale The National Federation of Licensed Practical Nurses (NFLPN) is the official membership organization for licensed practical nurses (LPNs) and licensed vocational nurses (LVNs). The National League for Nursing (NLN) and the National Association of Practical Nurse Education (NAPNE) are focused on nursing education and are not limited to LPNs/LVNs. The American Red Cross is a volunteer organization with members who may or may not be nurses.

Which organization established the Department of Practical Nursing Programs and developed the accreditation service called the Council of Practical Nursing Programs? Frontier Nursing Service National League for Nursing Association of Practical Nurse Schools National Federation of Licensed Practical Nurses

National League for Nursing Rationale The National League for Nursing established the Department of Practical Nursing Programs and developed the accreditation service called the Council of Practical Nursing Programs. Mary Breckenridge established the Frontier Nursing Service to deliver obstetric care to mothers in rural Kentucky. The Association of Practical Nurse Schools was organized to address the needs of practical nursing education. The National Federation of Licensed Practical Nurses has set standards for practical and vocational nursing practice to promote and protect the interests of licensed practical nurses and licensed vocational nurses and to educate and inform the general public about practical and vocational nursing.

A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? Inform the client of the results. Ensure that the results are placed in the client's medical record. Notify the client's healthcare provider of the results. Request the test be re-done to ensure accuracy

Notify the client's healthcare provider of the results. Rationale The nurse is most ethically and legally accountable for reporting diagnostic testing results to the client's healthcare provider, whether the results are normal or, more importantly, abnormal. Informing the client of the results is an incorrect action in this situation. Placing the results in the client's record and obtaining normal values of the results from the lab are acceptable actions for the nurse after notifying the healthcare provider of the abnormal results. It is inappropriate for the nurse to request that the test be re-done.

A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation? Counsel the nurse about the problem. Ignore the problem until it happens again. Notify the nurse manager about the problem. Resolve the problem by sending the nurse home.

Notify the nurse manager about the problem. Rationale The assessment phase of problem solving consists of collecting data. The next step involves exploring options to address the problem; this is best accomplished in collaboration with the nurse manager. Counseling the nurse about the problem is not the role of a nurse; the nurse who has been drinking needs professional counseling. Ignoring the problem until it happens again is unsafe; clients may be placed in jeopardy. Resolving the problem by sending the nurse home delays addressing the problem.

Which type of charting originates from the nursing process? PIE DARE SOAPE SOAPIER

PIE Rationale In Charting by Exception (CBE) method of documentation, the nurse uses more detailed flow sheets. PIE (Problem, Intervention, and Evaluation) is one such format that originates from the nursing process to enhance the focus on existing concerns. DARE (Data, Action, Response and evaluation, Education and patient teaching) is the acronym for four different aspects of charting using the focus format. SOAPE (subjective, objective, assessment, plan, evaluation) is also similar to PIE but it originated from the medical model. SOAPIER (Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision) is an acronym for seven different aspects of charting.

Which client assessment finding should the nurse document as subjective data? B/P 120/82 Pain rating of five (5) Potassium 4.0 mEq Pulse oximetry reading of 96%

Pain rating of five (5) Rationale Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.

Two nurses are planning to help a client with one-sided weakness to move up in bed. What should the nurses do to conform to proper body mechanics? Instruct the client to position one arm on each shoulder of the nurses. Direct the client to extend the legs and remain still during the procedure. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. Rationale Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.

For which health care team role are the principles of the delegation process outlined according to the American Nurses Association (ANA)? Registered nurse Licensed practical nurse Licensed vocational nurse Unlicensed nursing personnel

Registered nurse Rationale The ANA has outlined the principles of the delegation process for registered nurses. Licensed practical nurses, licensed vocational nurses, and unlicensed nursing personnel are the delegatees and do not manage the delegation process.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. Prayer Hypnosis Medication Aromatherapy Guided imagery

Prayer Hypnosis Aromatherapy Guided imagery Rationale Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and non-opioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

The nurse is providing education about the use of restraints to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? Prevent a client from pulling out an IV when there is concern that the client cannot follow instructions or is confused. Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Maintain immobilization of a client's leg to prevent dislodging a skin graft. Keep an older adult client from falling out of bed following a surgical procedure.

Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Rationale Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for being unable to sleep and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what? Promote gluconeogenesis. Produce an anti-inflammatory effect. Promote cell growth and bone union. Decrease pain medication requirements

Promote cell growth and bone union. Rationale There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. High protein intake during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain

Which type of home health care agency is most likely to be owned by corporate chains and be profit oriented? Official agency Voluntary agency Proprietary agency Hospital-based agency

Proprietary agency Rationale Proprietary agencies are a part of home health care agency; they are associated with corporate chains and are profit driven. Official agencies are part of home care agency; they are authorized by law to deliver services to a defined area or community. Voluntary agencies deliver nursing care in the home. The hospital-based agency is a type of home care agency that gets most of its referrals from the hospital itself.

Which is the briefer adaptation of the charting format for the POMR (Problem-Oriented Medical Record)? SBAR DARE SOAPE SOAPIER

SOAPE Rationale SOAPE (Subjective, Objective, Assessment, Plan, and Evaluation) is the briefer adaptation of the charting format for the POMR (Problem-Oriented Medical Record). SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation. DARE (Data, Action, Response and evaluation, Education and patient teaching) is the acronym for the four different aspects of charting using focus format. SOAPIER (Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision) is an acronym for seven different aspects of charting.

What are the key features of assisted living in a residential care setting? Select all that apply. Emphasis only on resident's dignity Services available 24 hours a day Provides services to meet scheduled needs Services provided to promote independence Emphasizes privacy and a homelike environment

Services available 24 hours a day Services provided to promote independence Emphasizes privacy and a homelike environment Rationale The key features of assisted living in a residential care setting are that they provide services for 24 hours per day and services to promote independence. They also emphasize privacy and a home-like environment. The assisted living emphasis is on a resident's dignity and autonomy. The assisted living key feature is to provide services to meet both scheduled and nonscheduled needs.

What is the mental process most sensitive to deterioration with aging Judgment Intelligence Creative thinking Short-term memory

Short-term memory Rationale During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in its blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory, and susceptibility to personality changes. There should be little or no change in judgment. There is little or no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life.

Which epithelial tissue is only involved in absorption by osmosis? Simple columnar Simple squamous Stratified squamous Stratified transitional

Simple squamous Rationale Simple squamous epithelial tissue is only involved in absorption by osmosis. The function of simple columnar epithelial tissue is involved in protection, secretion, and absorption. Stratified squamous epithelial tissue and stratified transitional epithelial tissue are involved in protection.

Which rehabilitation team member plays a role in designing a rehabilitation communication program? Physical therapist Clinical psychologist Speech-language pathologist Rehabilitation registered nurse

Speech-language pathologist Rationale A speech-language pathologist plays a role in designing a rehabilitation communication program. A physical therapist designs an exercise program. A clinical psychologist acts as an emotional evaluator. A rehabilitation registered nurse acts as a coordinator and educator.

In which phase of mitosis do the two nuclei appear? Prophase Anaphase Telophase Metaphase

Telophase Rationale During telophase, the two nuclei appear, and the chromosomes disperse. During prophase the formation of chromatids and spindle fibers occurs. During anaphase the cells start dividing. During metaphase the nuclear membrane and nucleolus disappear

A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers that the client has received burns due to incorrect settings when use of the heating pad was initiated. Which principle would legally apply? No one could be held liable for new equipment. The nurse could be held liable for the injury that occurred. The nurse did what a reasonable, prudent nurse would do. The manufacturer is liable for new equipment

The nurse could be held liable for the injury that occurred. Rationale A nurse can be held responsible for any action performed that causes a client to be harmed. Legally, someone will assume liability for the action. If sued in this case, the nurse would have to prove that her actions were reasonable and prudent under the circumstances. The manufacturer may also be liable depending on whether the equipment was used correctly, but initially the actions of the nurse will be reviewed.

What is the role of a case manager in a healthcare organization? To delegate work on the unit suitably To follow up with the client after discharge To provide direct care for the client at the bedside To unite the strategic direction of the organization

To follow up with the client after discharge Rationale A case manager is an advanced practice nurse who coordinates a client's acute care in the hospital and follows up with the client after discharge. A nurse manager delegates work appropriately to the nursing staff on the unit. A registered nurse provides direct care to the client at the bedside. The nurse executive is often the vice president or strategic director of nursing in a healthcare organization.