Study for Hesi #2

. A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply. Correct 1 Dry cerumen 2 Tears in the tympanic membrane Correct 3 Difficulty hearing high-pitched voices Incorrect 4 Decrease of hair in the auditory canal 5 Overgrowth of the epithelial auditory lining

1,3 Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier.

The nurse who is working during the 8 AM to 4 PM shift must document a client's fluid intake and output. An IV is infusing at 50 mL per hour. The client drinks 4 ounces of orange juice and 6 ounces of tea at 8:30 AM, and vomits 200 mL at 9:00 AM. At 10:00 AM the client drinks 60 mL of water with medications and voids 550 mL of urine at 11:00 AM. At 12:30 PM, 3 ounces of soup and 4 ounces of ice cream are ingested. The client voids 450 mL at 2:00 PM. Calculate the total intake for the 8 AM to 4 PM shift. Record your answer using a whole number. ___ mL

970 1 ounce = 30 mL; 1 cc =1 mL. 120 mL of orange juice at 8:30 AM. 180 mL of tea at 8:30 AM. 60 mL of water with medications at 10:00 AM. 90 mL of soup at 12:30 AM. 120 mL of ice cream at 12:30 AM (counted as a liquid because it melts at room temperature). 400 mL of IV fluid (50 mL × 8 hours = 400). Total intake is 970 mL.

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client? 1 It may turn the urine bright yellow. 2 The daily fluid intake should be increased. 3 The drug should be taken on an empty stomach. 4 It may accumulate in the body if an excessive amount is taken.

Bright yellow urine is an expected, insignificant side effect of vitamin B complex. There is no need to increase oral fluids; the client may consume the usual daily intake of fluid. Taking the drug on an empty stomach may precipitate nausea; therefore, it should be taken with food. Vitamin B complex is a water-soluble vitamin, and excess amounts are excreted in urine.

When considering Erikson's psychosocial developmental tasks, a nurse should focus care for middle-aged adults around their need to be: 1 Productive 2 Controlling 3 Independent 4 Autonomous Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

1 A psychosocial task for middle adulthood according to Erikson is generativity; this task is concerned with the sense of productivity and accomplishment. Controlling, being independent, and being autonomous are not involved in any task of middle adulthood identified by Erikson.

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1 Evaluation 2 Assessment 3 Nursing interventions 4 Proposed nursing care

1 An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned.

How can a nurse best evaluate the effectiveness of communication with a client? 1 Client feedback 2 Medical assessments 3 Health care team conferences 4 Client's physiologic responses

1 Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? 1 Tubing injection port 2 Distal end of the tubing 3 Urinary drainage bag 4 Catheter insertion site

1 The appropriate site to obtain a urine specimen for a patient with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample as the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for: 1 Falls 2 Impaired cognition 3 Imbalanced nutrition 4 Impaired gas exchange

1 The client is at risk for falls related to the leg prosthesis and history of syncope. There is no evidence or contributing factors in the patient scenario of the other nursing problems.

6. Evidence-based nursing uses a variety of sources to support nursing practice. Which are sources of evidence-based practice? Select all that apply. 1 Theory 2 Research 3 Time studies 4 Clinical expertise 5 Accepted nursing rituals

1,2,4 Evidenced-based nursing care uses information gleaned from theory, research, expert opinion, client history and physical examination, client preferences and values, and the clinical expertise of the nurse. Time/motion studies are not used as a basis of evidenced-based practice. Accepted nursing rituals are not used as a basis of evidenced-based practice.

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? (Select all that apply.) Correct 1 Gloves Correct 2 Gown 3 Mask Correct 4 Goggles 5 Shoe covers 6 Hair bonnet

1,2,4 Standard personal protective equipment (PPE), which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary. Shoe covers and hair bonnet are not required for the patient care situation described.

A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. Correct 1 Tremors 2 Lethargy Correct 3 Palpitations 4 Visual disturbances 5 Decreased pulse rate

1,3 Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia.

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of: 1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Generativity versus stagnation

2 According to Erikson, poor self-concept and feelings of despair are conflicts manifested in those who are older than 65 years of age. The initiative versus guilt conflict is manifested in early childhood between 3 and 6 years of age. The industry versus inferiority conflict is manifested during the ages from 6 to 11 years. The generatively versus stagnation conflict is manifested during middle adulthood, 45 to 65 years of age.

The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. In doing so, the nurse is aware that in the problem-etiology-signs and symptoms (PES) format: 1 Signs and symptoms come last in the diagnostic process. 2 Nursing interventions are derived from the etiology statement. 3 The only allowable diagnoses are nursing diagnoses. Nursing diagnoses deal only with actual or potential illness problems.

2 The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the "S" comes first in the diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses treat most frequently with other health care providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired.

The nurse performs a respiratory assessment and auscultates breath sounds that are high-pitched, creaking, and accentuated on expiration. Which term best describes the findings? 1 Rhonchi 2 Wheezes 3 Pleural friction rub 4 Bronchovesicular

2 Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and COPD. Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.

What are the best ways for a nurse to be protected legally? Select all that apply. 1 Ensure that a therapeutic relationship with all clients has been established. 2 Provide care within the parameters of the state's nurse practice act. 3 Carry at least $100,000 worth of liability insurance. 4 Document consistently and objectively.

2,4,5 Malpractice or negligence must be proven legally. If a nurse is providing the best possible care under the circumstances, and within the scope of nursing practice, it would be difficult to prove allegations. It is unrealistic that the nurse will have a therapeutic relationship with all clients. Liability insurance protects the nurse if found guilty and a monetary award is made, but it does not reduce the possibility of litigation. Consistent, objective, and clear documentation also support practice within legal parameters.

The nurse recognizes that a common conflict experienced by the older adult is the conflict between: 1 Youth and old age 2 Retirement and work 3 Independence and dependence 4 Wishing to die and wishing to live

3 A common conflict confronting the older adult is between the desire to be taken care of by others and the desire to be in charge of one's own destiny. The conflict between the young and old age may occur but is not common. The conflict between the retired and working may occur but is not common. The conflict between those wishing to die and those wishing to live may occur but is not common.

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? 1 Prejudice 2 Stereotyping 3 Assimilation 4 Ethnocentrism

3 Assimilation involves incorporating the behaviors of a dominant culture. Maintaining eye contact is characteristic of the American culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

A health care provider tells a client about the diagnosis of inoperable cancer and that the client does not have long to live. After the health care provider leaves, the client says to the nurse, "I feel fine. I probably only have the flu." The nurse determines that the client is in the denial stage of grief. What should the nurse do to help meet the client's emotional needs? 1 Reassure the client that everything will be all right. 2 Leave the client alone to confront feelings of impending loss. 3 Encourage the denial until the client is able to accept reality. 4 Allow the denial and be available to discuss the situation with the client. .

4 Allowing the denial and being available to discuss the situation with the client does not remove the client's only way of coping, and it permits future movement through the grieving process when the client is ready. Reassuring the client that everything will be all right is false reassurance. The client must not be abandoned; the nurse's presence is a form of emotional support. The client's denial should be neither encouraged nor removed; encouraging denial is a form of false reassurance

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1 Anger 2 Denial 3 Bargaining 4 Acceptance .

4 Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication

1. A nurse manager is informed that a community disaster drill will take place. The disaster scenario will include a bombing in a shopping mall with hundreds of casualties. What location should the nurse consider for triage of casualties when planning for this exercise? 1 In the hospital parking lot 2 At the scene of the disaster 3 In the emergency department 4 At the closest school gymnasium

4 Mass casualty events have triage at the scene to prevent overwhelming the hospital with casualties, while at the same time preventing the hospital from becoming a secondary target of additional attacks. The hospital parking lot is too close to the hospital to provide safety from additional attacks. Performing triage in the emergency department will quickly overwhelm the department and will interfere with provision of care to clients who will benefit from interventions. The closest school gymnasium may be too far from the scene of the disaster and may become a target of secondary attack

A client who weighs 176 pounds is to receive 8 mg/kg of cyclosporine (Sandimmune) daily to prevent organ transplant rejection. How many milligrams should the nurse administer each day? Record your answer using a whole number. ___ mg/day

640 First compute the client's weight in kilograms and then compute the dosage. Solve the problem using ratio and proportion.

A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? 1 Inform the client of the results. 2 Ensure that the results are placed in the client's medical record. 3 Notify the client's health care provider of the results. 4 Obtain results of the other lab tests that were performed.

3 The nurse is most ethically and legally accountable for reporting diagnostic testing results to the client's health care provider, whether the results are normal or, more important, 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 health care provider of the abnormal results.

The nurse is caring for a client that is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? 1 Normal serum electrolyte levels 2 Healthy skin integrity 3 Resolution of peripheral edema 4 Improved hemoglobin and hematocrit level

4 Vitamin B12 is essential for appropriate maturation of red blood cells; therefore relieving the deficiency is expected to improve hemoglobin and hematocrit (H&H) levels and decrease hypoxia-related problems. This disorder is known as pernicious anemia. Normal serum electrolytes, healthy skin integrity, and resolution of peripheral edema if present would be secondary to improved hemoglobin and hematocrit levels.

A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a registered professional nurse. What group primarily is protected under the regulations of the practice of nursing? 1 The public 2 Practicing nurses 3 The employing agency 4 People with health problems

1 Each state or province protects the health and welfare of its populace by regulating nursing practice. Although the members of the nursing profession can benefit also from a clear description of their role, this is not the primary purpose of the law. The employing agency does assume responsibility for its employees and therefore benefits from maintenance of standards, but this is not the purpose of the law. People with health problems are just one portion of the population that is protected; this answer is too limited.

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications

1 Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.

The nurse is caring for a client that had a hip replacement two days prior. After removing a bedpan from under the client, the nurse recognizes that a priority nursing intervention is to: 1 Provide perineal care. 2 Turn and position the client. 3 Give a complete bed bath. 4 Document the bowel movement.

1 Providing perineal care helps to preserve skin integrity for the client who is incapable to provide self-care. Turning and positioning the client after hip surgery who has decreased physical mobility is important in preventing skin breakdown but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area had been soiled with a bowel movement. Documenting the bowel movement has to be done only after meeting immediate needs of the client.

he nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past two weeks. The client states "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client? 1 "You are worried about paying your bills?" 2 "Don't worry; your bills will get paid eventually." 3 "When was the last time you were admitted for hyperglycemia?" 4 "You really shouldn't be drinking alcohol because of your diagnosis of diabetes"

1 Reflection can help the client to elaborate. The other examples are false assurance, use of professional jargon, and offering advice, which can all restrict the client's response.

he nurse teaches sterile technique to a family member of a client who is to be discharged with a large abdominal wound that requires a dressing change twice a day. The nurse concludes that further teaching is needed when the family member performs what action during a return demonstration? 1 Sets the sterile field on the client's linens at the foot of the bed 2 Touches the outer inch of the sterile field when placing it on a flat surface 3 Checks expiration dates on the sterile packages before donning sterile gloves 4 Picks up wet gauze with sterile plastic forceps holding the tips lower than the wris

1 The field should be placed on a clean, dry table near the client. A client's bed surface may not be clean and the client's movements may cause the field to become contaminated. The outer inch of the sterile field is considered contaminated. Sterile objects must be kept within the one-inch border of the sterile field. Expired equipment must be discarded. Sterile gloves are donned after the soiled dressing is removed and contained, the hands washed, and the sterile field is prepared. Holding the tips lower than the wrist is the correct technique if using forceps to hold wet gauze. This keeps the flow of the sterile solution in the direction of sterile equipment. If forceps are held with the tips higher than the wrist, sterile solution will flow in the direction of the caregiver and may become contaminated by flowing onto an unsterile surface.

A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? 1 Accept the client's behavior. 2 Explore the situation with the client. 3 Withdraw from contact with the client. 4 Tell the client the reason for the staff's actions.

2 At this time the client is using this behavior as a defense mechanism. Acceptance can be an effective interpersonal technique because it is nonjudgmental. Eventually, limits may need to be set to address the behavior if it becomes more aggressive or hostile. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies non-acceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered.

A client is hospitalized for treatment of severe hypertension. Captopril (Capoten) and alprazolam (Xanax) are prescribed. Shortly after admission, the client says, "I don't think any of you know what you are doing. You are just guessing what I need." What does the nurse determine as the probable cause of this behavior? 1 Denial of illness 2 Fear of the health problem 3 Response to cerebral anoxia 4 Reaction to the hypertensive drug

2 Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear. There is no evidence that the client denies the existence of the health problem. Although disorders such as brain attacks and atherosclerosis, which are associated with hypertension, may lead to cerebral anoxia, there is insufficient evidence to support this conclusion. Captopril (an antihypertensive) is a renin-angiotensin antagonist that reduces blood pressure and does not cause behavioral changes; alprazolam is prescribed to reduce anxiety.

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? 1 Anger 2 Denial 3 Bargaining 4 Depression

2 Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1 Evidence 2 Tort discovery 3 Proximate cause 4 Common cause

2 Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's.

The most appropriate time for a nurse manager to schedule a 30-minute nursing education class is: 1 On each employee's day off 2 At the overlap of each shift 3 During the first part of each shift after report 4 Any day of the week after the staff members' lunch breaks

2 Scheduling the class at the half-hour overlap of each shift economically and conveniently accommodates the most staff members while ensuring that there are enough nurses present to care for clients. Scheduling an educational session when some staff members are not reimbursed for their time contributes to low morale and resentment. If the class is scheduled during the first half hour of a shift after report, client care may be jeopardized. The nurses on the previous shift will have left and the unit will be understaffed during the class. Scheduling the class any day of the week after the staff's lunch breaks provides education only to staff members working on the day shift; more than one class needs to be scheduled. In addition, it may leave the unit understaffed during the class.

Which client assessment finding should the nurse document as subjective data? 1 B/P 120/82 2 Pain rating of five (5) 3 Potassium 4.0 mEq 4 Pulse oximetry reading of 96%

2 Subjective data is obtained directly from a client. Subjective data is 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.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1 Limit the client's fluid intake. 2 Teach the client how to exercise the legs. 3 Encourage use of the incentive spirometer. 4 Maintain the knee gatch position at an angle. e.

2 The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. An incentive spirometer improves pulmonary function but does not prevent venous stasis. Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal spac

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids. 2 Administer oxygen. 3 Take the temperature. 4 Collect a sputum specimen.

3 Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics

A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client's plan of care include? 1 Foster self-activity whenever possible. 2 Plan care to be completed at one time followed by a long rest. 3 Teach family members how to assist with the client's basic care. 4 Limit visiting to evening hours before the client goes to sleep.

3 Because family members are old enough to understand the client's needs, they should be encouraged to participate in the care. Self-care increases oxygen use, thereby increasing fatigue and dyspnea. Overworking the client causes undue fatigue; there should be frequent rest periods between different aspects of care. Limiting visiting to evening hours deprives the client of a support system.

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1 Ringer's lactate 2 5% Dextrose and water 3 0.9% Normal saline 4 0.45% Normal saline

3 Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? 1 "I should carry objects about 18 inches from my body." 2 "I should sleep on my stomach with a firm mattress." 3 "I should carry objects close to my body." 4 "I should pull rather than push when moving heavy objects.

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

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1 Force urine to back up into the kidneys. 2 Suppress production of urine. 3 Cause the device to pull away from the skin. 4 Tear the ileal conduit.

3 If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 Raised to 30 degrees 4 Raised to 10 degrees

3 Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30-45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine, at 90 degrees or 10 degrees.

What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? 1 Makes the skin more supple 2 Avoids drying the skin as does alcohol 3 Eliminates surface bacteria that may contaminate the culture 4 Provides a cooling agent to diminish the feeling from the puncture wound

3 Povidone-iodine exerts bactericidal action that helps eliminate surface bacteria that will contaminate culture results. Povidone-iodine does not make the skin more supple. It does dry the skin. Alcohol is not used because it is bacteriostatic; it inhibits, not eliminates, microorganisms. Although povidone-iodine may provide a cool feeling, this not a reason for its use.

A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond? 1 Allow the visitor to review the record; sponsors have access to privileged information. 2 Ask the primary health care provider about granting permission to the sponsor. 3 Do not allow the sponsor to review the record. 4 Allow the visitor to review the record; clients with alcoholism need reassurance from sponsors.

3 The Health Insurance Portability and Accountability Act (HIPAA) stipulates that clients' records are confidential and may be seen by only those who are associated with the direct care of the client. Although the sponsor can receive permission from the client to review the record, only those who have direct care responsibilities for the client can see it. Viewing a client's records is not allowed according to the privacy laws, despite the health care provider's approval. Although clients with a diagnosis of alcoholism need reassurance from their sponsors, it can be offered without reviewing the client's progress report.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? 1 Justice 2 Veracity 3 Autonomy 4 Beneficence

3 The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.

A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that the legal term that best describes this situation is: 1 False threats 2 Assault and battery 3 False imprisonment 4 Breach of confidentiality .

3 The hospital is threatening to keep the infant; therefore false imprisonment is threatened. False imprisonment is restraining or confining a person without a clinical reason. False threat may be a term to describe false imprisonment; however it is inaccurate in this situation. Assault and battery legally means to threaten violence and the physical act of violence. Breach of confidentiality is a disclosure to a third party, without client consent or court order of private information

A nurse speaking in support of the best interest of a vulnerable client reflects the nurse's duty of: 1 Caring 2 Veracity 3 Advocacy 4 Confidentiality

3 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.

An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. The nurse identifies that a factor of special concern when caring for this client is the client's: 1 Irritability in response to deprivation 2 Decreased ability to recall recent facts Correct3 Inability to maintain an optimal level of functioning 4 Gradual memory loss resulting from change in environment

3 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.

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by: 1 Providing more oxygen to lung tissue. 2 Adding pressure to lung tissue, which improves gas exchange. 3 Opening collapsed alveoli and keeping them open. 4 Opening collapsed bronchioles, which allows more oxygen to reach lung tissue.

3 The primary mechanism of PEEP is to deliver positive pressure to the lung at the end of expiration. This helps to open collapsed alveoli and keep them open. With the primary mechanism of PEEP to open the alveoli and maintain them open, exchange of carbon dioxide and oxygen can take place more efficiently, thus improving oxygenation by providing more oxygen to the lung tissue and improving gas exchange. PEEP may have an indirect effect on opening bronchioles.

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? 1 "You will need to ask your health care provider; it is not part of the usual tests for people your age." 2 "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." 3 "It is performed routinely starting at your age as part of an assessment for colon cancer." 4 "There must have been a positive finding after a digital rectal examination performed by your health care provider."

3 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).

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1 faint, barely detectable. 2 slightly weak, palpable. 3 normal. 4 bounding.

3 The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. Palpation should be done using the fingertips and intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1 + indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished pulse than normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? 1 Stop the heparin, flush the line, and administer the vancomycin. 2 Use a piggyback setup to administer the vancomycin into the heparin. 3 Start another IV line for the vancomycin and continue the heparin as prescribed. 4 Hold the vancomycin and tell the health care provider that the drug is incompatible with heparin.

3 The vancomycin and heparin are incompatible in the same IV and therefore must be administered separately. By instituting a second line for the antibiotic, heparin can continue to infuse. Twice a day both drugs must run concurrently. Also, flushing the line may not eliminate remnants of the heparin, which is incompatible with vancomycin. Using a piggyback setup to administer the vancomycin into the heparin is unsafe because heparin and vancomycin are incompatible and should not be administered via the same intravenous line. The client has two medications prescribed, and it is a nurse's responsibility, not the health care provider's, to administer them safely.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: 1 Promote equalization of osmotic pressures. 2 Prevent hypoxia associated with diaphoresis. 3 Promote integrity of intracerebral neurons. 4 Reduce brain metabolism and limit hypoxia.

4 Cooling blankets and antipyretic medications can induce hypothermia thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.

A nurse manager is evaluating the effectiveness of a disaster drill during which nurses were sent from their usual assignments to the emergency department. Which criterion should be used for the nurse manager to evaluate care during the disaster drill? 1 Number of fatalities 2 Cost of nurse overtime 3 Nurse-to-client ratio on units 4 Completion of critical pathways

4 During a disaster, nursing coverage on all units should remain appropriate for client safety. Disaster nursing is concerned with providing care for clients in imminent danger and requires mobilization of people and resources from other areas. Number of fatalities is not the basis for evaluating the effectiveness of care; during a disaster, many clients may be dead on arrival. Cost is not the concern during a disaster. Completion of critical pathways is not the basis for evaluation of care during a disaster. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

What should the nurse include in dietary teaching for a client with a colostomy? 1 Liquids should be limited to 1 L per day. 2 Non-digestible fiber and fruits should be eliminated. 3 A formed stool is an indicator of constipation. 4 The diet should be adjusted to include foods that result in manageable stools.

4 Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and also produce stools that are manageable depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Food high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet.

The nurse is caring for a client that underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely from: 1 A normal response to the analgesic 2 Oral dryness caused by nasal packing 3 An adverse reaction to anesthesia 4 Bleeding posterior to the nasal packing

4 Frequent swallowing may indicate bleeding in the posterior pharynx. Oral dryness causes thirst, not an increase in swallowing. Frequent swallowing is not a normal response to rhinoplasty or analgesics/anesthesia.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? 1 Side-lying with head elevated 45 degrees 2 Sims with head elevated 90 degrees 3 Semi-Fowler's with legs elevated 4 High Fowler's using the bedside table as an arm rest

4 High Fowler's position elevates the clavicles and helps the lungs to expand, thus easing respirations. The other options do not promote more comfortable breathing.

nurse is caring for a client who had head and neck surgery. Postoperatively, the nurse positions the client's head in functional alignment to prevent the complication of: 1 Cervical trauma 2 Laryngeal spasm Incorrect3 Laryngeal edema 4 Wound dehiscence

4 Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can precipitate wound dehiscence. The cervical vertebrae are designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema.

The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first? 1 Apply pressure to the site. 2 Obtain vital signs. 3 Change the client's gown and bed linens. 4 Assess the catheterization site.

4 Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client's gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized.

The nurse is providing information about blood pressure to Unlicensed Assistive Personnel (UAP) and recalls that the factor that has the greatest influence on diastolic blood pressure is: 1 Renal function 2 Cardiac output 3 Oxygen saturation 4 Peripheral vascular resistance

4 Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin-angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic blood pressure.

A staff nurse on a medical-surgical unit has been assigned to care for a number of clients. The nurse decides to review their individual records before client contact. Which phase of the nurse-client relationship does this represent? 1 Working phase 2 Orientation phase 3 Termination phase 4 Preinteraction phase

4 The preinteraction phase is a preparatory phase of the planned therapeutic relationship. The working phase is the period in the relationship when individuals are occupied with achieving goals, and sharing facts and feelings. The orientation phase is the initial period of the interaction; it is an introductory or exploratory phase. The termination phase is the period in the relationship when individuals are beginning to separate and move toward independent paths.

A nurse is hired to work in a facility where the nurse assumes responsibility for a number of clients' needs. This nursing care delivery system is called: 1 Team nursing 2 Modular nursing 3 Functional nursing 4 Primary care nursing

4 This is the definition of primary care nursing. In team nursing there is a mix of staff members who provide care along with a team leader who usually is a registered nurse. In modular nursing clients are assigned according to geographic location and a variety of professionals are involved; this is similar to team nursing, but the teams are smaller. In functional nursing the nurse manager makes work assignments with specific tasks for each nurse.

. A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? 1 Asking about what type of foods the client usually eats 2 Telling the client that the diet must be followed exactly as written 3 Telling the client that the intake of foods on the list must be limited 4 Asking about what the client knows about the diet that was prescribed

4 This question may validate the client's understanding; the response may indicate the need for further teaching or that the client understands; understanding and accepting the need for restrictions will increase adherence to the diet. Assessing the client's food preferences and teaching about diets follow an assessment of the client's understanding about the need for a specific diet; the client must understand the need for and the benefits of the diet before there is a readiness for learning. Telling the client that the diet must be followed exactly as written and telling the client that the intake of foods on the list must be limited are authoritarian and should be avoided

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention 4 An unconscious means of reducing stress

4 When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved