passpoint

After the nurse has taught the parents of a 5-year-old boy who has leukemia how to talk with their child about death and dying, which of the following would indicate that the parents have age-appropriate expectations about their child's reaction to his impending death?

"He might think he has caused his death because he has misbehaved." Explanation: A 5-year-old child is in the preoperational stage of cognitive development and thinks of death as temporary. Also, a child this age commonly thinks about behavior as magical; thus, the child may think that his behavior can cause death. Generally, children under 3 years of age are unable to differentiate death from temporary separation and are unable to understand what is happening. Logical thinking, evidenced by accepting death due to his disease, would occur during Piaget's stage of concrete operations, which occurs between ages 6 and 12 years. Although a 5-year-old child will be able to understand that he will be missed, he lacks the cognitive development to understand the extent of how much his siblings will miss him.

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond?

"I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." Explanation: Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 1 year by an experienced health care provider. Discussing this situation at a later time or checking with the physician to give the client something to relax does nothing to address the client's immediate concerns. Advising the client to wait until all tests are normal is a vague response and provides the client with little information.

After discussing preconception needs with a nulliparous client of Asian descent, which of the following client statements indicates the *need for further instruction*?

"If I become pregnant, I can continue to eat sushi twice a week." Explanation: The client needs further instructions when she says, "If I become pregnant, I can continue to eat sushi twice a week." Raw fish, including tuna, should be avoided while the client is pregnant because of the risk of contamination with mercury and other potential teratogens. Folic acid supplements taken before the client gets pregnant and during pregnancy can help reduce the risk of neural tube defects. Steaming vegetables reduces the risk that vitamins will be lost in the cooking water. Soy products can increase the client's protein levels.

On the second day after surgery, the nurse assesses an elderly client and finds the following: • BP 148/92, HR 98, RR 32 • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • Breath sounds coarse and wet bilaterally with a loose, productive cough • Client voided 100 ml very dark, concentrated urine during the last 4 hours • Bilateral pitting pedal edema Using the SBAR method to notify the health care provider of current assessment findings, which of the following is the most appropriate recommendation?

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

When developing the ongoing plan of care for the parents whose infant died of sudden infant death syndrome (SIDS), the nurse should plan to accomplish which of the following on the second home visit?

Allow the parents to express their feelings. Explanation: The goal of the second home visit is to help the parents express their feelings more openly. Many parents are reluctant to express their grief and need help. The goal of the first visit is to help the parents understand the disease and what happened. The first visit also provides time to help the parents understand that they are not to blame. Although it is important to assess the impact of SIDS on siblings, this is not the primary goal for the second visit. However, the nurse must be flexible in case problems involving this area arise. Typically, parents are unable to deal with decisions such as having other children during the second visit because they are grieving for the child that they lost. This topic may be discussed later in the course of care.

A neonate born to a primipara at 36 weeks' gestation in a small, rural hospital is to be transferred by ambulance to a level III nursery. To prepare the parents for the transfer, which of the following should the nurse include in the plan of care?

Allow the parents to touch the neonate before transfer. Explanation: When a neonate is being transferred to a neonatal care center (level III nursery), the parents should be allowed to see and touch the neonate, if possible, before transfer. The parents should be given the location and telephone number of the unit to which the neonate is being transferred. This helps to keep the parents informed. The parents are already aware of the neonate's condition and should recognize that it is critical if the neonate is being transferred to a neonatal care center. Consent would be obtained upon initial admission, and further consent is not likely necessary. Asking whether the father would like to ride in the ambulance with the neonate during the transfer is inappropriate. Most ambulances or transferring vehicles (e.g., helicopters, airplanes) do not allow family members to accompany the ill client. Space in the motor vehicle, helicopter, or plane is limited

A nurse refers a client with severe anxiety to a psychiatrist for medication evaluation. The physician is most likely to order which psychotropic drug regimen on a short-term basis?

Alprazolam, 0.25 mg orally every 8 hours Explanation: Alprazolam's antianxiety properties make it the most appropriate medication for this client. It should only be given very short term because of its addictive apotential and the client should be weaned off from it. Benztropine is an antiparkinsonian agent used to control the extrapyramidal effects of such antipsychotic agents as chlorpromazine hydrochloride and thioridazine hydrochloride. Chlorpromazine is used to control the severe symptoms (hallucinations, thought disorders, and agitation) seen in clients with psychosis. Buspirone is an antianxiety agent but takes several weeks before it is effective in reducing anxiety. Thus it would not help this client who needs immediate assistance. Alprazolam provides immediate relief.

A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs?

"It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." Explanation: The severe emotional trauma the girl has experienced will likely make it difficult for her to be successful in an adoptive placement at the present time, whether that placement is with someone she knows (the nurse) or another adoptive family. Additionally, adoption by the nurse is inappropriate because it blurs the lines between her professional and personal life and is likely to confuse the client. It is clear that the client has many issues and that love alone is not likely to solve all her problems. Treatment at the residential facility will allow her to work through emotional issues in a more therapeutic environment. Though not currently ready for adoption, she may be ready for adoption in the future after sufficient treatment.

The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which of the following comments by the client supports the fact that the client may not need counseling?

"Since I've gotten over the death of my husband, I've had more energy and been more active than before he died." Explanation: Resolving grief and having increased energy and activity convey good mental health, indicating that counseling is not necessary at this time. Taking an antidepressant or having less energy and involvement with grandchildren reflects possible depression and the need for counseling. Wanting to be with her dead husband suggests possible suicidal ideation that warrants serious further assessment and counseling.

A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. The nurse should tell the client:

"You can take ginseng if you take it with a carbohydrate" Incorrect Correct response: "Taking ginseng will increase the risk of hypoglycemia."

A registered nurse is assigning care on the oncology unit and assigns the client with Kaposi's sarcoma and human immunodeficiency virus (HIV) infection to the licensed vocational nurse (LVN-LPN). The LVN-LPN states that she does not want to care for this client. How should the nurse respond?

"You seem worried about this assignment." Explanation: The registered nurse assigning care should first give the LVN-LPN the opportunity to explore his concerns and fears about caring for a client with HIV infection. Reassigning care for this client, assisting with care, and reviewing precautions do not address the present concern or create an environment that will generate useful knowledge regarding future assignments for client care

Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using a whole number.

800

The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which of the following clients would be an appropriate care assignment for this nurse?

A 72-year-old client with diverticulitis. Explanation: The client with diverticulitis will need care that the LPN should be able to provide safely. The client with angina is unstable and requires a registered nurse for continuous assessment. The client receiving chemotherapy treatment requires a registered nurse who is certified in chemotherapy administration. A child with Kawasaki's disease must be watched closely for cardiac complications, and it would be best to assign the child to an experienced pediatric nurse, not a new graduate.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

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

A nurse is coordinating outpatient care for a 38-year-old client who is homeless and has a history of chronic schizophrenia. Which one of the following interventions would be best for the nurse to suggest for this client?

A life and social skills group Explanation: A client with a history of chronic schizophrenia is in need of learning activities of daily living, communication, and other social skill deficits caused by his/her chronic illness. A job-planning workshop is outside the client's capabilities at this time. The need for a family mediator is not indicated. Solitary games and activities would not build the social structure and skills necessary for this client's progress.

The pediatric nurse is being pulled to the nursery for the day. The census is six neonates. Which three neonates are the best client care assignment for the pediatric nurse?

A nurse who is being pulled to a different unit would have a less complicated assignment than the nurse who regularly staffs that unit. The pediatric nurse would be assigned the recent admission with excellent Apgar scores, the one day old with a normal variation of caput succedaneum occurring from swelling of the infant's scalp most commonly from a long labor, and a 4 hour old with a bluish appearance to the hands and feet. The nurse would identify acrocyanosis as normal in the newborn period and cover the baby to warm. More complicated neonates with specific assessment and parental teaching needs include the breast fed neonate with jaundice, the 2 day old who has not had a meconium stool, and the neonate with cleft lip and palate. All neonates will need close observation and increased parental teaching.

A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff?

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

A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response?

Approach the client and ask if there are questions about the condition. This is the best therapeutic response that is client focused. The other answers do not demonstrate therapeutic response: nurses should not offer false assurances, and calling the family is not addressing the problem between nurse and client.

A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents?

Arrange a meeting between the health care team and the parents to develop a care plan. Explanation: A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge.

During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients take an active role in their health care?

Ask clients for their description of events and for their views concerning past medical care.

The nurse is caring for a very ill child with a large extended family. Members of the family repeatedly ask the same questions of the nurse and other healthcare team members. To effectively manage the accurate dissemination of information, which of the following should be the priority action by the nurse?

Ask the family to identify a spokesperson to be the communicator with the team. Explanation: In situations with large extended families where frequent updates are required or the state of the child is critical, it is imperative that a spokesperson be identified for receiving information and for disseminating the information to the extended family members

A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort?

Assault Explanation: Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program

Assessing present voiding patterns Correct Explanation: The guidelines for initiating bladder retraining include assessing the client's present intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.

A client and her partner experienced a pregnancy loss at 28 weeks gestation. The nurse is aware that which of the following factors affects the couple's response to this loss?

Assigned meaning to the event Explanation: It is important to gain some understanding of the parents' perception of their unique loss. The meaning of the loss is determined by familial and cultural systems of the parents. Previous experience with loss or loss of a pregnancy may affect the parents' response. Experience with children is not the factor. Expecting the potential of a loss and not a healthy birth outcome during pregnancy may prepare parents for the subsequent perinatal loss. Support from a spiritual leader may help some families, but not all families want this type of support.

The nurse is preparing an educational program on breast cancer for women at a Black community center. What information is important for the nurse to consider for the discussion?

Breast cancer concerns vary between socioeconomic levels of Black women. Explanation: The nurse needs to consider the beliefs and concerns for all socioeconomic levels of Black women when providing education on breast cancer. Access to screening and care may differ. Black women are more likely to develop breast cancer and be diagnosed later in the disease process than Caucasian women. Not all Black women believe that breast cancer is inevitable.

An 11-month-old infant is admitted to the hospital with severe diarrhea. In order to determine the severity of the diarrhea, the nurse should assess which of the following stool characteristics?

Consistency. Explanation: Diarrhea is best defined on the basis of stool consistency that is commonly liquid in nature. The color of diarrheal stools is usually greenish, but stool color is also affected by food and fluid intake. Stool odor is not directly related to diarrhea. It can vary widely and is not an accurate criterion to define diarrhea. Estimates of the amount of stool can vary widely. Therefore, this is not an accurate criterion by which to define diarrhea. The frequency of stools varies, although stools occur more frequently than normal when diarrhea is present.

The nurse is caring for a client who is ordered a contraction stress test (CST). The nurse is uncertain how to perform the procedure. Which of the following actions by the nurse would be most appropriate?

Consult the agency procedure book and follow the printed guidelines. Explanation: According to the American Nurses Association (Canadian Nurses' Association) Code of Ethics, if a nurse is uncertain about how to perform a procedure, the guidelines printed in the agency procedure book should be followed. Professional guidelines may not be conducive to, or align with, a particular agency's policy. Consulting with team members may be an appropriate strategy, but only after reading and following the agency procedure guidelines.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

Decreased acetylcholine level Explanation: A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic

A client with type 1 diabetes mellitus is admitted to the emergency department. Which respiratory pattern in a client with diabetes mellitus requires immediate action?

Deep, rapid respirations with long expirations are indicative of Kussmaul's respirations, which occur in metabolic acidosis. The respirations increase in rate and depth, and the breath has a "fruity" or acetone-like odor. This breathing pattern is the body's attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis.

A laissez-faire nurse-manager takes which action?

Delegates to staff responsibility for selecting a new nursing care delivery system (model) Explanation: Delegating a process that will affect all aspects of a nursing area shows a lack of accountability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff members for their opinions of the solutions is characteristic of a participative manager.

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact Explanation: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.

A 19-year-old unmarried college student is approximately 8 weeks pregnant asks the nurse, "If I have an abortion in the next 2 or 3 weeks, how will it be done?" The nurse instructs the client that at this gestational age an abortion is usually performed by which of the following techniques?

Dilatation and curettage. Explanation: When the gestation is less than 13 weeks, an elective abortion is usually performed by the dilatation and curettage method. Menstrual extraction, or suction evacuation, is the easiest method, but it is used only when the client is between 5 and 7 weeks' gestation. Dilatation and vacuum extraction is used when clients are between 12 and 16 weeks' gestation. Saline induction, used for clients between 16 and 24 weeks' gestation, involves instillation of a hypertonic saline solution into the amniotic sac to initiate expulsion. Oxytocin infusion may also be used with saline induction.

While performing continuous electronic monitoring of a client in labor, the nurse should document which information about uterine contractions?

Duration, frequency, and intensity

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse?

Encourage the family to identify their frustrations and fears.

Nurses are aware that variety and diversity occur both within and across groups. Which of the following factors leads to cultural benefits as a result of diversity?

Equal opportunity exists for various cultural perspectives. Correct Explanation: Culture benefits from diversity only when the playing field is level and when equal opportunity exists for various cultural perspectives. When a dominant culture overpowers the outward public expressions of other cultures, conflicts and suppression may occur in people of differing cultural orientations. Such situations can be highly stressful.

The nurse has asked the patient care assistant (PCA) to ambulate a client with Parkinson's disease. The nurse observes the PCA pulling on the client's arms to get the client to walk forward. The nurse should:

Explain how to overcome a freezing gait by telling the client to march in place. Explanation: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bedrest. A muscle relaxant is not indicated.

A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department?

Gonorrhea Explanation: Gonorrhea must be reported to the public health department. Bacterial vaginitis, genital herpes, and HPV aren't reportable diseases.

A scrub nurse in the operating room has which responsibility?

Handing surgical instruments to the surgeon Explanation: The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies.

The nurse-manager of the pediatric unit notices that vital signs are frequently not being documented on children returning from surgery. Which of the following approaches will be most effective for the unit manager to use to improve documentation?

Have a group of staff nurses review the established standards of care for postoperative clients. Explanation: According to principles of total quality management (TQM), a proactive, participative approach to improving all aspects of client care—the nurse-manager would have a group of staff members review the established client care standards and make suggestions. Talking to the staff members individually will not promote a participative group approach to setting standards. Having a meeting may pinpoint issues; however, using a small group that will first review the standards and make recommendations will empower the nurses to change. In TQM, participative, action-oriented approaches, not blame or punishment, are used to improve care.

special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

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

The nurse assesses a client and notes a weak, irregular pulse, as well as soft, flabby muscles. The nurse should assess the client further for:

Hypokalemia. Explanation: Common clinical manifestations of hypokalemia include ventricular arrhythmias; weak and irregular pulse; soft and flabby muscles; and decreased deep tendon reflexes. Hypercalcemia causes confusion and decreased memory, bone pain, polyuria, and nausea, vomiting, and constipation. Hypernatremia causes signs of fluid volume deficit. Hypomagnesemia is manifested by tremors, confusion, hyperactive deep tendon reflexes, and seizures.

A client with a history of Addison's disease is experiencing weakness and headache. The vital signs are blood pressure of 100/60 and heart rate of 80. Laboratory values are Na 130, potassium 4.8, and blood glucose 70. Which of the following would the nurse expect to administer?

IV normal saline and glucocorticoids Explanation: The client with Addison's is expected to have hypotension and inadequate corticosteroids. There is no evidence that the client would be anemic. Although the blood pressure may be a little below normal, there is no indication for an inotropic drug such as dopamine to increase perfusion. There is no indication that the client would be weak and hypoglcemic.

When assessing a dark-skinned client for cyanosis, the nurse should examine which of the following?

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

A client with a history of osteoarthritis is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes?

Including the client in developing a care plan that works toward meeting discharge goals Explanation: Involving the client in the care plan development optimizes client outcomes; alternating periods of activity and rest helps optimize parti

The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent?

Influence of the extended family Explanation: The influence of the extended family is the cultural factor that is causing the nurse's dilemma. It is common for English-speaking women to defer to an extended family member in both formal and informal decision-making situations. Language barriers may present challenges at times, but translators may be involved in particular when discussing health-related decisions to ensure understanding.

When completing the Preoperative Checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?

Inform the nurse anesthetist. Explanation: The nurse anesthetist administers the anesthetic agent and monitors the client's physical status throughout the surgery; the nurse anesthetist must have knowledge of all known allergies for client safety. The completed chart (with the Preoperative Checklist) accompanies the client to the operating room; any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the chart. The pre-anesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure.

A client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should:

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

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse *requires further intervention*?

Keeping the client in one position to decrease bleeding Explanation: The student nurse *shouldn't* keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

A client of Anglo-Saxon descent (eg, Anglo-American or English Canadian) reports to the primary health care facility with symptoms of fever, cough, and running nose. While interviewing the client, which of the following points should the nurse keep in mind?

Maintain eye contact while talking. Explanation: While interviewing a client of Anglo descent, the nurse should maintain eye contact, because it indicates openness and sincerity. Such clients freely express positive and negative feelings; therefore, the nurse may probe into emotional issues. Anglo culture is an open culture, and members of this culture don't mind providing personal information. Also, clients of Anglo descent are not threatened by closeness, so the nurse does not have to sit in another corner of the room.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?

Making a copy of the incident report for the client Explanation: A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the physician of the incident and the client's condition.

Which of the following approaches to chronic pain management is most effective?

Multidisciplinary approach. Explanation: A multidisciplinary approach to pain relief is needed for greatest effectiveness. In addition to the client, the nurse, and the physician, others who may be needed on the team include a social worker, an occupational therapist, a dietitian, and a psychologist or a psychiatrist. Pain relief interventions based on physiologic and psychological principles can be used simultaneously to obtain greater pain relief. Medication administration is only one option for reducing pain.

A "read-back" procedure has been implemented on a nursing unit to prevent discrepancies in telephone orders and reports. This procedure should be implemented when the:

Nurse receives a critical laboratory value via phone or in-person from the laboratory Explanation: For any verbal or telephone order or result, it is important to read back the information to ensure its accuracy. It is also important to document that it was read back according facility policy. It is not necessary to use "read-back" procedures when data are entered on the computerized health record. The unit clerk is not a licensed health care worker and should not take telephone orders. When giving a written report, it is not necessary to "read back" but the nurse should always clarify if there is any question.

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)?

Obtaining vital signs during blood administration Explanation: The nurse may safely delegate obtaining vital signs during blood administration to the LPN. Teaching the client taking warfarin about follow-up care, assessing a hip wound, and taking a telephone order are actions that must be taken by the registered nurse because they aren't within the scope of LPN practice.

Which of the following is the most common initial manifestation of acute renal failure?

Oliguria

Which moral principle is a nurse applying when she decides what is best for a client and acting without consulting the individual?

Paternalism Explanation: Nurses and other health care workers employ paternalism when a client's loss of consciousness or other circumstances compel them to decide what is best for the client and to act without consulting the individual. Beneficence means that nurses should act in the client's interests always. Fidelity requires the nurse to be faithful and truthful and to keep promises to clients, families, coworkers, and employers. Autonomy refers to every individual's right to make rational decisions about his life. The nurse's belief in autonomy leads to a respect for the client's decisions.

A nursing instructor has assigned a student to care for a client of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preferences are important for the student to consider when caring for this client?

People of Asian descent prefer some distance between themselves and others. Explanation: Clients of Asian descent are more comfortable with some distance between themselves and others. Direct eye contact may be considered impolite or aggressive within the Asian culture, and they may tend to avoid direct eye contact and avert their eyes while speaking with another.

A client is brought to the emergency department following an automobile accident. Physical assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. Which of the following actions is the nurse's most appropriate action?

Preparing the client for a chest tube insertion

The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which action should the nurse do next?

Provide gentle support to the fetal head. Explanation: During a precipitous birth, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent too rapid of emergence leading to injury. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Priority should be given to safe birth of the infant over protecting the perineum by massage.

A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action?

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

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose?

Reduced serum ammonia levels. Correct Explanation: Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels. It is not used to stimulate bowel peristalsis, even though diarrhea can be a side effect of the drug. Lactulose does not have any effect on edema, ascites, or hemorrhage.

The widow of a client who successfully completed suicide tearfully says, "I feel guilty because I am so angry at him for killing himself. It must have been what he wanted." After assisting the widow with dealing with her feelings, which intervention is most helpful?

Refer her to a group for survivors of suicide. Explanation: The survivor of suicide, in this situation, would be referred to a group for survivors of suicide to help her with her feelings and to work through the grief reaction. This group provides support and understanding of what the individual is experiencing by members who are experiencing similar reactions, including anger and guilt. Depression and unresolved grief can occur when the survivor does not receive appropriate help. Counseling by a chaplain or individual therapy by the nurse may be appropriate in addition to referral to the group. Giving the survivor the suicide hotline number would be appropriate if the survivor herself were thinking about suicide.

A nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She's in her 30s and has two young children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?

Refer the client to a community support program. Explanation: The client isn't withdrawn and doesn't show other signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences, a formal community support group. The nurse may educate the client's spouse or partner and listen to his concerns, but the nurse shouldn't tell the client's spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She can't be expected to be cheerful at all times.

A client with end-stage pancreatic cancer has decided to terminate medical intervention. What should a nurse anticipate when consulting with palliative care?

Referral for bereavement counseling Explanation: Referral to a bereavement counselor may help the client and his family make decisions about unfinished business. This client should continue to receive pain medications, antidepressants, and nutritional therapy at home and in the hospice setting. It isn't appropriate to decrease these comfort measures

What is the primary goal of nursing care during the emergent phase after a burn injury?

Replace lost fluids. Explanation: During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock. Preventing infection and controlling pain are important goals, but preventing circulatory collapse is a higher priority. It is too early in the stage of burn injury to promote wound healing.

Risk factors associated with testicular malignancies include:

Residing in a rural area. Explanation: The incidence of testicular cancer is higher in men who live in rural rather than suburban areas. Testicular cancer is more common in white than black men. Men with higher socioeconomic status seem to have a greater incidence of testicular cancer. The exact cause of testicular cancer is unknown. Cancer of the testes is the leading cause of death from cancer in the 15- to 35-year-old age-group.

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

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

A client is prescribed alfuzosin for benign prostatic hyperplasia (BPH). What should the nurse teach the client?

Rise slowly from a supine position. Correct Explanation: First-dose phenomenon, which is a severe and sudden drop in blood pressure after the administration of the first dose of an alpha-adrenergic blocker, can cause clients to fall or pass out. All clients must be warned about this adverse effect before they take their first dose of an alpha blocker. Orthostatic hypotension can occur with any dose of an alpha blocker, and clients must be warned to get up slowly from a supine position. The client needs to consult with the healthcare provider if the heart rate falls below 60/bpm. There is no fluid restriction with this medication. A dry cough is a side effect of an ACE inhibitor.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?

Risk for infection Explanation: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

A client with end-stage heart failure is preparing for discharge. The client and his caregiver meet with the home care nurse and voice their concern that setting up a hospital bed in the bedroom will leave him feeling isolated. Which suggestion by the home care nurse best addresses this concern

Set up the hospital bed in the family room so the client can be part of household activities.

A nurse is completing an admission interview of a client newly diagnosed with multiple myeloma. The client tells the nurse he is concerned that his insurance coverage and limited savings will not pay for all of his family's needs when he is not working. Based on this information, to whom would the nurse initiate a referral?

Social services

A nurse is about to admit a client to the medical surgical unit directly from the healthcare provider's office. Upon assessment, the nurse notes that the client has significant periorbital edema. Laboratory values indicate the presence of proteinuria and hypoproteinemia. Which of the following is the nurse's priority action?

Strict intake and output assessment and documentation Explanation: Symptoms are highly suggestive of glomerulonephritis. Clients require strict intake and output are generally placed on a high protein diet. Monitoring of laboratory values is good nursing practice overall, but not the priority with this diagnosis. Ambulation is not the priority, as client requires rest.

The charge nurse on the postpartum unit has received report about a client with a fetal demise who will be ready for transfer out of Labor and Birth in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?

Talk to the mother first and decide on a location that is mutually agreeable. Explanation: The nurse on the postpartum unit should discuss with the client what her wishes are and mutually agree on a location. The charge nurse better understands the current and future needs of the client experiencing this type of loss as the client may or may not be thinking well or clearly at the moment.

A nurse is caring for a client with advanced heart failure. He can't care for himself and hasn't been able to eat for the past week because of dyspnea. The client doesn't want a feeding tube inserted and expresses his desire for "nature to take its course." The client's family is pleading with him to have a feeding tube inserted. What is the most appropriate action for the nurse to take?

Talk with the client's family about the client's right to decide for himself. Explanation: Advocating for a client's wishes is a key nursing role. It's especially important when a client's family disagrees with his wishes. The nurse should be sure that the client has all the information he needs to make an informed decision. Then she should support his decision. She shouldn't contact a clergyman without the client's consent, call a family conference, or schedule intubation in violation of the client's wishes.

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?

The chaplain, because his educational background includes strategies for handling grief Explanation: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation time isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.

A client with chronic obstructive pulmonary disease has a new prescription for *theophylline*. Which of the following information obtained from the client would prompt the nurse to consult with the healthcare provider?

The client takes *cimetidine* 150 mg daily. Explanation: Cimetidine interferes with the metabolism of theophylline and may cause theophylline toxicity. Theophylline should be taken as prescribed even if the client is not experiencing any symptoms of shortness of breath. An elevated heart rate is an expected side effect of theophylline and moderate exercise in a client with COPD. Thick mucus production is also an expected symptom of COPD.

A client experienced the loss of her home and beloved family dog in flood waters 4 months ago. The client states that since the loss, she finds it hard to "feel anything." The client says she can't concentrate on simple tasks, thinks about the flood incessantly, and fears losing control. The client reports that she becomes extremely anxious whenever the flood is mentioned and must leave the room if people talk about it. The admitting nurse suspects the client has post-traumatic stress disorder (PTSD). Which nursing goal would be most appropriate for this client?

The client will demonstrate progress in dealing with the grief of losing his/her home and dog. Explanation: Survivors of trauma, disasters, and events outside of the usual ranges of human experiences may experience PTSD. The client is displaying dysfunctional grieving, which is common in PTSD. The priority for the nurse is to help the client gain adaptive coping strategies. Although sleep loss is an issue with PTSD, assisting the client with her grief would have the most impact on the client's behavior. Acclimation to the unit should not be an issue to the client with PTSD. The client will have difficulty avoiding thoughts of the trauma due to the persistent nature of PTSD.

The unconscious client is to be placed in a right side-lying position. The nurse should intervene when observing a client in which of the following positions?

The left arm is rested on the mattress with the elbow flexed. Explanation: The client is not in proper body alignment if, when in the right side-lying position, the client's left arm rests on the mattress with the elbow flexed. This positioning of the arm pulls the left shoulder out of good alignment, restricting respiratory movements. The arm should be supported on a pillow. The client's head also should be placed on a small pillow to keep it in alignment with the body. The right leg should be extended on the mattress without a pillow to avoid hyperrotation of the hip. A pillow should be placed between the left and right legs with the left knee flexed so that on no parts of the legs is skin touching skin.

When providing care on an Indian reservation (First Nations reserve), a nurse has prioritized assessments for type 2 diabetes mellitus and fetal alcohol syndrome. How should the nurse's practice be best understood?

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

The nurse-manager of a 20-bed coronary care unit is off duty when a staff nurse makes a serious medication error. The client, who received an overdose of medication, nearly dies. Which statement accurately reflects the nurse-manager's accountability?

The nursing supervisor will notify the nurse-manager at home. Explanation: The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible.

The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next?

Use a Doppler ultrasound device. Explanation: When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the physician may be necessary if there is a change in the client's condition.

A nurse is discussing possible risk factors related to surgery with a client. Considering that the client belongs to the Navajo culture, which of the following approaches should the nurse adopt to prevent any misunderstandings?

Use a hypothetical third person. Explanation: The nurse should discuss the risk and complications related to surgery using a hypothetical third person. People belonging to Navajo culture view talking about possible risks in an informed consent discussion as ill-intended and even malicious because of their belief that speaking ill causes ill. In these situations, discussing risks and side effects using a hypothetical third person may be appropriate. Having a direct discussion may not be appropriate. Providing written information may not be appropriate because it prevents open communication between the nurse and the client.

A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:

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

The nurse is encouraging a nursing assistant to interact with a dying client and family. The nurse should help the nursing assistant understand that:

When health care personnel do not understand their own feelings about death and dying, they often avoid the client.

Which of the following indicatethat a client who has been raped will have future adjustment problems and the need for additional counseling?

When her parents show shame and suspicion about her part in the rape. Explanation: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims.

An elderly man experiences a thrombotic cerebrovascular accident and subsequent flaccid hemiplegia of the right side. When planning care for this client, rehabilitation begins:

When the client is admitted to the hospital. Explanation: Rehabilitation for a client who has sustained a cerebrovascular accident begins at the time he is admitted to the hospital. The first goal of rehabilitation should be to help prevent deformities. This goal is achieved through such techniques as positioning the client properly in bed, changing his position frequently, and supporting all parts of his body in proper alignment. Passive range-of-motion exercises may also be started, unless contraindicated.

How should the nurse ensure correct documentation of this telephone order?

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

The nurse understands that with the right help at the right time, a client can successfully resolve a crisis and function better than before the crisis, based primarily on which factor?

acquisition of new coping skills

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem?

espiratory distress syndrome Explanation: Respiratory distress syndrome is more common in neonates born by cesarean section than in those born vaginally. During a vaginal birth, pressure is exerted on the fetal chest, which aids in the fetal inhalation and exhalation of air and lung expansion. This pressure is not exerted on the fetus with a cesarean birth. Congenital anomalies are not more common with cesarean birth. Pulmonary hypertension occurs more commonly in infants with meconium aspiration syndrome, congenital diaphragmatic hernia, respiratory distress syndrome, or neonatal sepsis, not with cesarean birth. Meconium aspiration syndrome occurs more commonly with vaginal birth, postterm neonate, and prolonged labor, not with cesarean birth.

A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother:

how the child's condition today differs from his normal condition. Explanation: The nurse should ask how the child's condition differs from his normal condition in order to identify the chief complaint. Asking how long the child has been like this may be interpreted poorly by the caregiver. The nurse shouldn't ask if the child can walk without holding onto furniture because focusing on what the child can do — not on what he can't do — preserves the family's self-esteem. Focusing on negative aspects of the child's behavior, such as constant drooling, is inappropriate.

In which areas of the United States and Canada is the incidence of tuberculosis highest?

inner-city areas Explanation: Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence.

Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the:

maxillofacial injury and gurgling respirations. Explanation: Emergency department triage involves employing the Emergency Severity Index (ESI) as the triage tool to assess which clients should be seen first and what resources they will need; it is a 5 level algorithm with 1 given the highest priority. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway which would be considered a Level 1. The spinal cord injury client doesn't exhibit immediate airway needs and would be considered a Level 2. The client with the severe head injury and no blood pressure has a grave prognosis. Although the client in early labor, early labor doesn't surpass airway compromise in importance and would be assigned a level 2.

The State Health Department notifies a nursery staff nurse of a phenylketonuria (PKU) metabolic screening test result of [7 mg/dl (423.5 mcmol/L)] for a neonate discharged several days ago. What should the nursery nurse do?

mmediately notify the physician because the test result is critically elevated. Explanation: A normal test result for PKU metabolic screening is < [2 mg/dl 121 mcmol/L)]; a level of [7 mg/dl (423.5 mcmol/L)] is critically elevated.

A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important?

ncreasing fluid intake to 3 L/day Explanation: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. Doing so helps empty the bladder of contaminated urine and prevents calculus formation. Administering a sitz bath would increase the likelihood of fecal contamination. Using an indwelling urinary catheter could cause further contamination. Encouraging the client to drink cranberry juice to acidify urine is helpful but isn't the most important intervention.

A registered nurse on the neonatal unit appropriately uses the chain of command when she:

notifies the unit manager of unresolved issues between the nursing unit and housekeeping personnel. Explanation: The concept of chain of command requires that the nurse contact the nurse-manager for issues related to other departments; the nurse-manager should handle such issues. Contacting the laboratory manager, asking the unit manager to grant her vacation requests, and e-mailing the housekeeping supervisor aren't appropriate uses of the chain of command

Which client action should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy?

nsisting on wearing a T-shirt and gym shorts rather than pajamas Explanation: Adolescents struggle for independence and identity, needing to feel in control of situations and to conform to peers. Control and conformity are often manifested in appearance, including clothing, and this carries over into the hospital experience. The adolescent feels best when he is able to look and act as he normally does, for example, wearing a T-shirt and gym shorts. Adolescents normally want to interact with peers and commonly seek every opportunity to do so. Avoiding other adolescents on the nursing unit or not taking phone calls from friends might suggest ineffective coping behavior. Refusing to fill out the menu and allowing the nurse to do so demonstrate dependent behavior, not a healthy coping mechanism.

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which of the following?

referral. Explanation: Referring is the process of sending or guiding a client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about his or her treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which stage of grief?

shock Explanation: The physical appearance of the anomaly and the life-threatening nature of the disorder may result in shock to the parents. The parents may hesitate to form a bond with the neonate because of the guarded prognosis. Denial would be evidenced if the parents acted as if nothing were wrong. Bargaining would be evidenced by parental statements involving "if-then" phrasing, such as, "If the surgery is successful, I will go to church every Sunday." Anger would be evidenced if the parents attempted to blame someone, such as health care personnel, for the neonate's condition.

A nurse is working with a group of parents whose children have died from cystic fibrosis. The group is talking about "acceptance." Two parents discuss their unwillingness to accept their son's death. The nurse should understand that:

some individuals find the idea of "accepting" the death of a loved one unachievable. Explanation: Although acceptance is considered to be the final stage of grief, some deaths, including out-of-life-cycle deaths, may never be accepted. To insist that a parent should work toward this goal would not likely be helpful. Rather it would be beneficial for the nurse to explore the parents' relationship with their deceased child. There is no evidence that these parents are experiencing denial or need more support from the group. Assuming that an individual isn't at the right stage is unreasonable and presumptuous, given the considerable variations in people's responses to loss.

A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for:

starting oxygen. Explanation: The infant is experiencing signs and symptoms of respiratory distress indicating the need for oxygen therapy. Sedation will not improve the infant's respiratory distress and would likely cause further respiratory depression. If the infant's respiratory status continues to decline, she may need to be transferred to the pediatric intensive care. Oxygen should be the priority as it may improve the infant's respiratory status. A chest CT is not indicated. However, a CXR would be another appropriate recommendation for this infant.

A nurse is caring for a client with diabetes insipidus. The nurse should anticipate administering:

vasopressin. Correct Explanation: Vasopressin is given subcutaneously to manage diabetes insipidus. Insulin is used to manage diabetes mellitus. Furosemide causes diuresis. Potassium chloride is given for hypokalemia.

The client phones the outpatient surgery center following skin biopsy on the left shoulder. The client states that the site continues to drain pinkish drainage and is uncomfortable. Which triage questions are appropriate to evaluate the client's concern? Select all that apply.

• "On which day did you have the biopsy completed?" • "Can you describe the drainage that you see." • "What is your pain level on a 0-10 pain scale?" • "How are you cleaning the area?"

A 10-year-old child visits the pediatrician's office for his annual physical examination. When the nurse asks how he's doing, he becomes quiet and states that his grandmother died last week. A child this age is likely to make which statements about the concept of death? Select all that apply.

• "Once you die you never come back." • "My grandmother's death has been hard to understand." • "My grandmother died because she was sick and nothing could make her better." Explanation: By age 10, most children know that death is irreversible and final. However, a child may still have difficulty understanding the specific death of a loved one. School-age children should be able to identify cause-and-effect relationships, such as when a terminal illness causes someone to die. Adolescents, not school-age children, understand that death is a universal process. Preschoolers see death as temporary and may think of death as a punishment.

A nurse is participating in a diabetes screening program. Who of the following is (are) at risk for developing type 2 diabetes? Select all that apply.

• A 32-year-old female who delivered a 9½-lb (4,309-g) infant. • A 44-year-old Native American (First Nations) person who has a body mass index (BMI) of 32. • A 55-year-old Asian who has hypertension and two siblings with type 2 diabetes. • A 12-year-old who is overweight. Explanation: The risk factors for developing type 2 diabetes include giving birth to an infant weighing more than 9 lb (4,082 g); obesity (BMI over 30); ethnicity of Asian, African, Native American, or First Nations; age greater than 45 years; hypertension; and family history in parents or siblings. Childhood obesity is also a risk factor for type 2 diabetes. Maintaining an ideal weight, eating a low-fat diet, and exercising regularly decrease the risk of type 2 diabetes.

The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of which of the following? Select all that apply.

• Discussion of pertinent information • The client's agreement to the plan of care • Freedom from coercion

The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the nursing assistant? Select all that apply.

• Obtaining vital signs. • Applying antiembolic stockings. • Keeping the client oriented. Explanation: It is appropriate for the nurse to delegate obtaining vital signs and applying antiembolic stockings to the nursing assistant. The nursing assistant can also help keep the client oriented to time, person, and place by talking with the client. The registered nurse is responsible for evaluating the quality and character of the client's vital signs, but the assistant may take the vital signs and report readings to the nurse. It is the registered nurse's responsibility to assess the client's need for oxygen therapy and apply as needed in accordance with physician's orders. It is also the registered nurse's responsibility to perform the nursing history and assess the client's breath sounds.

A female client with which condition would be at risk for increased severity of vulvovaginal candidiasis? Select all that apply.

• uncontrolled diabetes • immunosuppression due to cancer • human immunodeficiency virus (HIV) infection Women with underlying medical conditions, such as uncontrolled diabetes and HIV infection or cancer-causing immunosuppression, correlate with an increasing severity of candidiasis. Hypertension and asthma are not related to immunosuppression or complicated candidiasis.