ATI Fundamentals 1 Quiz
A nurse is caring for a client just diagnosed with TYPE 1 DM. The client is RESISTENT TO LEARNING SELF INJECTION of insulin and asks the nurse to administer all injections. The nurse explains the importance of self care and appropriately adds which of the following statements? A. "Tell me what i can do to help you overcome your fear of giving yourself injections." B. "I am sure your physician will not be pleased that you refuse to give yourself insulin injections." C. "In the meantime, I'm sure your spouse will be able to learn how to give you the insulin injections." D.
A. "Tell me what I can do to help you overcome your fear of giving yourself injections." RATIONALE: this illustrates the therapeutic communication tool of clarifying and offering self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections. Option B illustrates the non-therapeutic communication block of focusing on inappropriate issues or people and showing disapproval. It is also threatening to the client. Option C illustrates the non-therapeutic communication block of focusing on inappropriate people or issues, placing the client's feelings "on hold" and giving false reassurance.
When ADMITTING a client, the nurse RECORDS which information in the client's record FIRST? A. Assessment of the client B. The plan of care for the client C. Nursing interventions performed for the client D. Evaluation of the client's progress
A. Assessment of the client RATIONALE: the nurse should document the findings of the client's assessment to provide information about the health status of the client on admission. This is the first step of the nursing process and takes place prior to the subsequent steps. Planning, interventions, and evaluation are not the first step of the nursing process. Generally the nurse documents as soon as possible after performing these actions described. TEST-TAKING STRATEGY: with a priority-setting question where all the options appear correct, but various stages of the nursing process are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.
A nurse is planning interventions for a group of clients who are OBESE. What can the nurse do to improve THEIR COMMITMENT TO A LONG TERM GOAL of weight loss? A. Attempt to develop the client's self-motivation B. Keep detailed records of each client's progress C. Use a system of rewards for reinforcing behavior D. Involve family members in the process
A. Attempt to develop the client's self-motivation RATIONALE: long term commitment to lifestyle changes is based on intrinsic motivation. Each individual must choose to take the actions necessary for health changes. Option B will help each client to track individual progress, but it does not necessarily increase commitment. Although rewards can be used and may be helpful, extrinsic rewards do not help with long-term goal commitment. Although family support can be important, this will not necessarily improve clients' commitment to long term goals.
A nurse on a rehab unit is TRANSFERRING a client from a BED TO A CHAIR. To AVOID A BACK INJURY, which of the following techniques should the nurse use? A. Bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae B. Have the client lock hands around the nurse's neck so that the client will feel more secure during the transfer C. Place the bed in an elevated position so that the client's hips are at the same level as the nurse's hips, making the center of gravity the same for both individuals D. Bend at the waist while maintaining a wide stance. Lift the client to a standing position, and then pivot the client toward the chair
A. Bend at the knees while maintaining wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae RATIONALE: bending at the knees results in the use of the large muscles of the legs. Keeping the back straight avoids using the small, easily injured back muscles. When the client's hands rest on the nurse's shoulders, security is provided for the client. Placing then hands under the client's axillae avoids placing pressure on the chest, which can be uncomfortable for the client. If the client's hands are locked around the nurse's neck and the client starts to fall, all of the client's weight is placed on the nurse's cervical vertebrae, which can result in a serious injury. The bed should be in the low position so the client can sit if unable to stand. With the bed elevated, the client cannot sit back down on the bed if he feels weak or faint because the bed is too high. Bending at the waist places strain on the small lower back muscles, which are prone to injury.
A client is admitted to the hospital with DECREASED CIRCULATION IN THE LEFT LEG. During the ADMISSION ASSESSMENT, which is the MOST IMPORTANT nursing action INITIALLY? A. Evaluate the pedal pulses B. Obtain the client's medical history C. Measure the client's vital signs D. Ask if the client is experiencing any pain in the leg
A. Evaluate the pedal pulses RATIONALE: assessing the reason for the client's admission is essential and is the most important initial action. It provides the nurse with an admission baseline for comparison during later assessments. The nurse should check the pedal pulses in the feet of BOTH legs to compare the degree of decreased circulation in the "bad" leg with that in the "good" leg. The client's medical history and measuring the client's vital signs is important and provides baseline information for planning care, but they are not priority assessments. Option D is part of the nurse's physical assessment but it is not the highest priority.
An OLDER ADULT client just diagnosed with COLON CANCER asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate? A. Help the client write down questions to ask the provider so the client doesn't forget B. Assure the client that the provider will discuss what he is planning C. Tell the client to have a family member call the provider D. Provide the client with articles from several magazines or journals that discuss colon cancer
A. Help the client write down questions to ask the provider so the client doesn't forget RATIONALE: forgetfulness is often a part of the aging process. Since the provider will be making rounds soon, this action addresses the client's needs. Option B represents the communication blocks of putting the client's concerns on hold and giving false assurance. The nurse does not know what the provider plans to discuss with the client. The nurse must always be in a therapeutic and advocacy role and should address the client's needs, feelings, and concerns. Option C represents the communication blocks of putting the client's concerns on hold and referring to an inappropriate person (the family member). Having the client tell a family member to call implies that the client's concerns can wait and that someone else is more important or more competent than the client. Option D would address the client's need for information, but this option fails to address the client's uncertainty about what the provider is going to prescribe. It is also inappropriate because published material may confuse or intimidate the client.
A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the MOST SIGNIFICANT factor in PLANNING DIETARY CHANGES for this client is the A. Involvement of the client in planning the change B. Emphasis the provider places on the dietary changes C. Financial ability of the client to make the dietary changes D. Extent of the dietary changes planned for the client
A. Involvement of the client in planning the change RATIONALE: a client who is actively involved in planning dietary changes is more receptive to the changes and is more likely to adhere to them. The provider's approach and the extent of change is important when planning dietary changes but is not the highest priority in this situation. If finances are an obstacle, the nurse can advocate for the client by referring him to the appropriate social service agencies.
A nurse prepares to admit a client who is immediately POSTOPERATIVE to the unit following ABDOMINAL SURGERY. When TRANSFERRING, the client from the GURNEY TO THE BED, the nurse should A. Lock the wheels on the bed and stretcher B. Have the client use the trapeze bar to assist C. Have at least four people help with the transfer D. Use a draw sheet to move the client
A. Lock the wheels on the bed and stretcher RATIONALE: locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client. This is the priority action for transferring a client. It is a safety risk for a client who is just returning from surgery to use a trapeze bar to assist with a transfer from a gurney to a bed. Four people may or may not be needed for a transfer. It depends on the client's size and ability to help, and on the strength of the staff performing the transfer. Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client who has just had abdominal surgery. Look for an option that provides for the client's safety during the transfer.
A nurse is caring for a client who has HYPERTENSION. Which approach is the PRIORITY when the nurse is measuring the client's BLOOD PRESSURE? A. Obtain BP under the same conditions each time B. Record BP with the client sitting on the side of the bed C. Place the BP cuff on the right arm above the elbow D. Measure BP with the client in supine position
A. Obtain BP under the same conditions each time RATIONALE: the nurse should record the client's position in the chart so that the next reading may be done with the client in the same place and position. Options B and D are appropriate approaches, but they are not the nurse's priority. Option C is an appropriate approach unless it is contraindicated in that limb (i.e. after mastectomy).
To use proper BODY MECHANICS while MAKING AN OCCUPIED BED for a client on bed rest, the nurse should A. Place the bed in a high horizontal position B. Make sure the side rails are down C. Ask the client to roll as far as possible onto her side D. Place the bed in semi-Fowler's position
A. Place the bed in a high horizontal position RATIONALE: to use correct body mechanics, the nurse should raise the bed to a high horizontal position. This helps to avoid excessive bending and stretching. Putting the side rails down is unsafe for the client and does not address the nurse's proper use of body mechanics. While it is appropriate for the client to roll side to side while the nurse is making the bed, this action has no impact on maintaining proper body mechanics. The nurse cannot make the bed correctly while it is in semi-fowler's position. The nurse would have to reach while making the head of the bed, which strains the musculoskeletal system. It will also cause the linen to pull out when the nurse lowers the head of the bed.
A nurse tells a client that the provider has prescribed IV fluids. The client APPEARS to be upset about the IV catheter insertion, but SAYS NOTHING to the nurse. Which of the following is an appropriate nursing RESPONSE? A. "The doctor wants you to have antibiotics, and this method eliminates getting frequent injections." B. "Is there something about this procedure that concerns you?" C. "Do you have any questions about the procedure?" D. "It only hurts a little bit. It'll be over before you know it."
B. "Is there something about this procedure that concerns you?" RATIONALE: with this response, the nurse uses the therapeutic communication tools of clarification and offering self. The nurse inquires about the client's concerns (feelings) and offers self by suggesting that they talk about both the procedure and the client's feelings. Option A illustrates non-therapeutic communication technique of focusing on an inappropriate person (the provider) or an inappropriate issue (antibiotics by injection). This is a block to communication since the client's feelings aren't addressed. Option C illustrates the communication block of placing the client's feelings on hold. With this statement, the nurse focuses on the procedure, not on the client's feelings. Option D illustrates the communication blocks of false assurance and the uses of a cliche. A venipuncture hurts more than a bit. This response ignores the client's feelings while making a false statement to the client.
When initiating CPR, the nurse must confirm which of the following ASSESSMENT findings PRIOR to beginning CHEST COMPRESSIONS? A. Dilated pupils B. Absence of pulse C. Absence of respirations D. Unresponsiveness
B. Absence of pulse RATIONALE: prior to beginning chest compressions, it is essential that the nurse assess for the absence of a pulse. The carotid site is assessed for 5-10 seconds. If no pulse is felt, then chest compressions are begun. Performing chest compressions on a client who has a pulse can lead to cardiac dysrhythmias and death. Dilated pupils (failure of the pupils to react to light) will eventually occur as the brain is deprived of oxygen, but this is a late sign and is not assessed when initiating CPR. The nurse should assess for the absence of respirations prior to beginning rescue breaths. Establishing unresponsiveness is required before beginning. It is done prior to establishing an airway or beginning ventilations.
A post-op client has been diagnosed with PARALYTIC ILEUS. When performing AUSCULTATION of the client's ABDOMEN, the nurse expects the BOWEL SOUNDS to be A. Decreased B. Absent C. Hyperactive D. Normal
B. Absent RATIONALE: paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent. Bowel sounds are not normal, decreased, or absent with a paralytic ileus.
A nurse is precepting a newly licensed nurse who is preparing to help a client perform TRACHEOSTOMY CARE. The nurse SHOULD INTERVENE if the equipment the preceptee gathered included A. Hydrogen peroxide B. Cotton balls C. A clean towel D. A small brush
B. Cotton balls RATIONALE: cotton ball particles can enter the tracheostomy opening, causing aspiration. Half-strength hydrogen peroxide is used to clean the inner cannula. A clean towel is useful for protecting the bed linens and client's gown. Pipe cleaners or a small brush may be used to remove thick or crusty secretions from the inner cannula. TEST-TAKING STRATEGY: a negative-format question requires an INAPPROPRIATE option to be the CORRECT answer.
Which of the following should a group of COMMUNITY HEALTH NURSES plan as part of a PRIMARY PREVENTION program for OCCUPATIONAL PULMONARY DISEASES? A. Job rotation B. Elimination of the exposure C. Improved ventilation D. Screening tests for at-risk employees
B. Elimination of the exposure RATIONALE: primary prevention measures are those intended to PREVENT the onset of a TARGETED DISORDER. Elimination of the exposure is the best way to avoid the undesirable outcome. The primary prevention of occupational diseases is achieved only through the reduction or elimination of exposures to chemical, physical, or biological hazards, for example, by wearing personal protective equipment. Job rotation does not guarantee a primary prevention. In some industries, job rotation may reduce exposure; in others, it will not have any significant effect on exposure. Improved ventilation is not a primary prevention because it may reduce exposure but does not PREVENT it. Screening tests for at-risk employees are considered SECONDARY PREVENTION. Secondary prevention measures are those that identify and treat ASYMPTOMATIC people who have already developed RISK FACTORS or PRE-CLINICAL DISEASE.
A nurse is caring for a client diagnosed with a TERMINAL ILLNESS. The client ASKS SEVERAL QUESTIONS about the NURSE'S RELIGIOUS BELIEFS related to death and dying. An appropriate nursing response is to A. Change the topic since the client is trying to divert attention from the illness to the nurse B. Encourage the client to express his thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the hospital's chaplain
B. Encourage the client to express his thoughts about death and dying RATIONALE: the nurse must recognize the client's need to talk about impending death and encourage the client to discuss his thoughts on the subject. Depending on the situation, the nurse may also want to share some thoughts on this topic. Self-disclosure is a communication skill that can help open the lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skill of offering self and listening to the client's thoughts is appropriate. Changing the subject is a non-therapeutic communication technique that will block the development of open communication between the nurse and the client. The close-ended response of option C is a non-therapeutic communication technique that will block communication with this client. The response of option D places the client's issue "on hold" and could cause barriers to communication between the nurse and client.
A client comes to the emergency department REPORTING THAT HE HAS HAD DIARRHEA for 4 days and is urinating less than usual. When ASSESSING the client's SKIN TURGOR, the nurse should A. Push on a fingernail bed until it blanches, release it, and note how long it takes the skin to become pink B. Grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back C. Press the skin in above the ankle for 5 sec, release it, and note the depth of the impression D. Measure the skin fold thickness at the upper arm using a pair of calibrated skin fold calipers
B. Grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back RATIONALE: this is the correct technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the grasped fold of skin will immediately return to normal; with dehydration, the skin will remain tented. Option A is the technique for assessing capillary refill. Option C is the technique for determining how much pitting edema a client has. Option D is the technique for determining a client's body fat percentage.
To use the NURSING PROCESS correctly, the nurse must FIRST A. Identify the goals for the client's care B. Obtain information about the client C. State the client's nursing care needs D. Evaluate the effectiveness of the client's care
B. Obtain information about the client. RATIONALE: while stating the client's needs, identifying goals, and evaluating the effectiveness of the client's care is an appropriate step in the nursing process, it is not the first step. The collection of data, or assessment, is the first step in the nursing process.
A nurse is demonstrating POST-OP DEEP BREATHING & COUGHING exercises to a client about to undergo EMERGENCY ABDOMINAL SURGERY for appendicitis. The nurse realizes the client may be UNPREPARED TO LEARN if the client A. Says he understands but does not want to demonstrate the procedure B. Reports severe pain C. Asks the nurse how often deep breathing should be done after surgery D. Tells the nurse that this exercise will probably be painful after surgery
B. Reports severe pain RATIONALE: a client who is experiencing severe pain is not able to concentrate and therefore is not ready to learn a new activity. Although a return demonstration indicates to the nurse that the client understands and is able to perform the activity, the nurse can not assume that a client who does not want to demonstrate it does not understand it. The nurse should use therapeutic communication techniques to collect further data about the client's knowledge and reluctance to perform the procedure pre-operatively. Asking about the frequency of the activity indicates to the nurse that learning has taken place. The client is motivated to perform the activity and wants to know how often to do it. Option D indicates to the nurse that the client is motivated to learn since it tells the nurse that the client knows the possible effects of this activity when he will have an abdominal incision. TEST-TAKING STRATEGY: with a negative-format question, the CORRECT answer will be an INCORRECT client response.
An assistive personnel says to the nurse, "This client is INCONTINENT of stool 3-4 times a day. I GET ANGRY, and i think that the client is doing it just to get attention. I think we should put adult diapers on her." Which is the appropriate nursing response? A. "You are probably right. Soiling the bed is one way of getting the staff's attention." B. "Changing the bed and cleaning the client must be tiresome. Next time i'll help you." C. "It is very upsetting to see an adult client regress." D. "I think you should try not to judge your client's behavior."
C. "It is very upsetting to see an adult client regress." RATIONALE: this option illustrates the therapeutic communication tool of restating and clarifying. It encourages the AP to express any feelings about the client soiling the bed for attention. Option A illustrates the non-therapeutic communication block of agreeing and showing approval, and it does not address the AP's anger. Option B shows empathy on the part of the nurse, but it is not only impractical but it does not address the AP's anger. Option D is a non-therapeutic response because it offers advice instead of focusing on how the AP feels. In addition, it has a condescending and scolding tone, which is likely to shut down any further communication between the nurse and the AP.
While measuring a client's vital signs, the nurse notices an IRREGULARITY in the HEART RATE. Which nursing action is appropriate A. Call the provider and request an order for a Holter monitor recording for the next day B. Request the assistance of another staff member and take simultaneous apical/radial pulse C. Count the apical pulse for 1 full minute and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 seconds
C. Count the apical pulse for 1 full minute and describe the rhythm in the chart RATIONALE: if the pulse is irregular, it must be counted for a full minute to obtain an accurate rate. The irregularity should be described in the client's medical record. A Holter monitor recording the next day may be too late to address and identify the client's immediate need. A simultaneous apical/radial pulse is used to identify a deficit between the apical and radial pulses. It is not used to assess irregularity in the pulse. Assessment of all peripheral pulses is appropriate for a client with a cardiovascular problem related to the adequacy of circulation to each extremity rather than the regularity of the heart rate.
A 3 YR OLD CHILD has had MULTIPLE TOOTH EXTRACTIONS while under general anesthesia. The client returns from the PACU crying, but awake, from the recovery room. Which APPROACH is likely to be successful? A. Do not examine the mouth B. Examine the mouth first C. Examine the mouth last D. Medicate the child for pain before examining the mouth
C. Examine the mouth last RATIONALE: it is always appropriate to leave the most distressing part of a physical exam of a toddler until the end. Since the mouth is the area of discomfort, examining it is likely to cause more crying and uncooperative behavior for the remainder of the assessment. The child just had oral surgery and is at risk for hemorrhage and swelling. It is imperative that the mouth be examined. The child must be assessed for pain before pain medication can be administered.
A nurse is caring for an OLDER ADULT CLIENT who is CONFUSED and CONTINUALLY GRABS at the nurses. Which of the following is an nursing action? A. Move the client to his room B. Apply restraints to the client's wrists C. Firmly tell the client not to grab D. Assign an assistive personnel to sit with the client
C. Firmly tell the client not to grab RATIONALE: setting limits by telling the client not to grab people is an effective way of dealing with this behavior. Moving the client to his room away from people is a type of seclusion and is not indicated in this situation. Isolating the client may also increase his agitation and may be unsafe. Applying wrist restraints increases a confused client's restlessness and agitation. Also, there is no indication that the client is at risk, so wrist restraints cannot be justified "for the client's safety." It is unrealistic to assign an AP to sit with the client to stop this behavior.
Before donning gloves to perform a procedure, proper HAND HYGIENE is essential. The nurse understands that the MOST IMPORTANT ASPECT of HAND HYGIENE is the amount of A. Water B. Soap C. Friction D. Time
C. Friction RATIONALE: alcohol-based hand rubs or sanitizer are now recommended by the CDC for hand hygiene between clients in situations when the hands are not visibly soiled. The hand rub is applied and the hands are rubbed briskly until dry. If traditional soap and water are used, friction is the most important component for removing micro-organisms. While the use of plenty of running water, enough soap, and adequate time for scrubbing is essential to proper hand hygiene, it is not the most important aspect.
A nurse is caring for a client who requires RECTAL temperature monitoring. Available at the client's bedside is a thermometer with a LONG, SLENDER TIP. Which of the following is an appropriate action for the nurse to take. A. Carefully insert thermometer after lubricating the end B. Estimate the client's temperature via palpation C. Obtain a thermometer with a short, blunt insertion end D. Don gloves before using the thermometer available. At the client's bedside.
C. Obtain a thermometer with a short, blunt insertion end RATIONALE: the thermometer that is available is an axillae or oral thermometer. It has a long, slender insertion end to provide more surface area contact with the tissues under the tongue or in the axilla. Because the bulb end is long and narrow rather than blunt, it has a greater potential for injuring the client's rectal tissue. Using this thermometer to obtain a rectal temperature is unsafe.
While starting an IV for a client, the nurse notices that her GLOVED HANDS get SPOTTED WITH BLOOD. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed? A. Wash the gloved hands and then throw the gloves away B. Prepare an incident report so that this occurrence will be documented C. Remove the gloves carefully and follow with hand hygiene D. Ask the provider to order a blood culture to determine risk
C. Remove the gloves carefully and follow with hand hygiene RATIONALE: standard precautions require the use of gloves and hand hygiene in the care of all clients. Unless there is a break in the nurse's skin, there is no need for an incident report or further investigation. Washing the hands while still gloved is unnecessary.
A client is admitted to the hospital in the TERMINAL stage of CANCER. The nurse enters the client's room to administer medications and finds the CLIENT CRYING. The APPROPRIATE nursing action is to A. Contact the family and ask them to say with the client B. Tell the client that someone will call his minister C. Sit and hold the client's hand D. Administer the client's medication and allow the client to cry privately
C. Sit and hold the client's hand RATIONALE: this action demonstrates the therapeutic communication tool of being silent, which conveys importance to the client. Holding the client's hand is a non-verbal way to express empathy. Option A does not respond to the client's immediate needs. Also, there is no indication that the client wishes to see family at this time. Option B illustrates the non-therapeutic communication block of putting the client's needs on hold. Also, there is no indication that the client wishes to see the minister at this time.
A client admitted with ABDOMINAL PAIN tells the nurse that her father died recently and she begins crying while talking about him. The nurse determines that the client's temperature is 39.2 C (102.6 F), her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give PRIORITY attention? A. The client is crying B. A soft, non-tender abdomen C. The client's temperature D. The client's menses is overdue
C. The client's temperature RATIONALE: An elevated temperature may be a sign of an infection or disease. A client with a temperature of 102.6 F is not well. This can affect her behavior, which may or may not be related to the death of her father. Crying is an expected part of the grieving process and the client's grief is a psychological consideration. However, this is not a priority finding. A soft, non-tender abdomen is an important assessment finding because of the client's report of pain. However, it is an expected finding and should not cause concern. Option D is an important assessment finding because of the client's report of pain. However, an irregularity in the menstrual cycle is a common finding when a client is stressed but this is not a priority finding. TEST-TAKING STRATEGY: with a priority-setting question where all four options appear plausible, rely on Maslow's hierarchy of needs to help set the priorities. Remember, clients with basic physiologic needs (sleep, food) come first, then clients with safety needs (security), love and belonging needs, self-esteem needs, and self-actualization needs. This client's physiologic need takes precedence over the other needs.
At the SURGICAL SCRUB SINK, a SURGICAL NURSE demonstrates the PROPER SURGICAL HANDWASHING TECHNIQUE by SCRUBBING A. For a minimum of 1 minute B. From the elbows down to the hands C. With her hands held higher than her elbows D. Minimal friction
C. With her hands held higher than her elbows RATIONALE: hands must be held higher than the elbows so that water and soap suds can drain away from the clean area toward the dirty area. Surgical scrubbing must last at least 5 minutes to decontaminate the skin adequately. An important principle of surgical handwashing is to scrub the hands first, then work toward the elbows. Scrubbing is performed with a specifically designed and pre-medicated brush. The use of mechanical friction is necessary to decontaminate the skin effectively.
An OLDER ADULT client appears AGITATED when the nurse requests that the client's DENTURES BE REMOVED PRIOR TO SURGERY and states, "I never go anywhere without my teeth." Which of the following is an appropriate nursing response? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires everyone to remove their dentures." D. "You seem worried. Are you concerned someone may see you without your teeth?"
D. "You seem worried. Are you concerned someone may see you without your teeth?" RATIONALE: this illustrates two therapeutic communication tools. One is empathy, which is shown by focusing on the client's feelings. The other is validation/clarification with which the nurse seeks to validate the reason for the client's feelings. Option A demonstrates the non-therapeutic communication block of ignoring or dismissing the client's feelings. Option B demonstrates the non-therapeutic communication block of disagreeing with the client and offering unsolicited advice. Option C demonstrates the non-therapeutic communication block of focusing on inappropriate issues or persons (the anesthesiologist).
A client scheduled for a HYSTERECTOMY has not signed the OPERATIVE CONSENT FORM yet. When the nurse approaches the client and asks that she review and sign the form, the client says that she no longer wants to have the surgery. AT THIS TIME, which action should the nurse take? A. Tell the client she has to sign the form because the surgery is already scheduled B. Cancel the surgery C. Inform the client's family about the situation D. Ask the client why she has changed her mind
D. Ask the client why she has changed her mind RATIONALE: the nurse has to find out the reasons for the client's decision to forgo the surgery. It may be a simple misunderstanding on the client's part, or she may still have some unanswered questions about the procedure. Option A is not appropriate because the client has the right to refuse to sign the consent. Cancelling the surgery is a decision between the surgeon and the client and is not the responsibility of the nurse. Option C is inappropriate because client confidentiality must be respected. The family may be notified only after the client requests the nurse to do so. TEST-TAKING STRATEGY: with a priority-setting question where all the options appear correct, but various stages of the nursing process are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.
A hospitalized client needs a CHEST X-RAY. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client's room, the PRIORITY action is to A. Explain the x-ray procedure to the client B. Help client into a wheelchair before transporter arrives C. Ask if the client has any questions D. Check the client's identification bracelet
D. Check the client's identification bracelet RATIONALE: once the client's identity is determined, the nurse can proceed with the other options. This action is the priority because it provides for the safety of the client. It is a nursing responsibility to be certain that each client receives only what has been prescribed for that client. Although explaining the procedure, having the client ready for the transporter, and answering any questions is an appropriate nursing action when preparing a client for a diagnostic test or procedure, but it is not the priority nursing action.
A client who is unstable and requires frequent vital signs has an ELECTRONIC BP MACHINE automatically measuring his bp EVERY 15 MIN. However, the machine is reading the client's BP at MORE FREQUENT INTERVALS AND THE READINGS ARE NOT SIMILAR. The nurse checks the machine settings and observes the additional readings, but the PROBLEM CONTINUES. Which of the following is the APPROPRIATE nursing action? A. Turn on the machine every 15 min to obtain client's BP B. Record only those BP readings needed for the 15-min intervals C. Obtain both manual and automatic readings and compare them D. Disconnect the machine and measure the bp manually every 15 minutes
D. Disconnect the machine and measure the bp manually every 15 minutes. RATIONALE: if reliability of the monitoring equipment is questioned, a manual process should be used. Also, malfunctioning equipment could pose a safety risk for the client, so it must be removed. Since the measurements and the operation of the machine appear to be questionable, operating the equipment differently cannot ensure the accuracy of the readings. Although the equipment is obtaining BP readings, the increased measurements and dissimilar results suggests that the machine is malfunctioning and thus all the readings are not accurate. Although option C appears to provide a means of checking the machine, the fact that it is not operating correctly already suggests that the accuracy of the readings is questionable.
A nurse's neighbor is scheduled for ELECTIVE SURGERY. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an INFECTION from a BLOOD TRANSFUSION. Which of the following is appropriate for the nurse to suggest? A. Asking the provider about taking (epoetin) Epogen before the surgery B. Taking iron supplements prior to the surgery C. Requesting that a family member donate blood D. Donating autologous blood before the surgery
D. Donating autologous blood before the surgery RATIONALE: autologous blood transfusion is the collection and re-infusion of the client's own blood. With pre-op autologous blood donation, the blood is drawn from the client 3-5 weeks before an ELECTIVE surgery and stored for transfusion at the time of surgery. While blood bank tests greatly reduce the risks of acquiring certain infectious diseases, these risks can not be eliminated entirely. Autologous blood is the safest form of blood transfusion; while taking Epogen prior to surgery may boost the client's hematocrit levels, it is inappropriate if the client already has an adequate hematocrit. In addition, this action may not eliminate the need and its related risks. While taking an iron supplement prior to surgery may boost the client's hemoglobin levels, it is inappropriate if the client already has an adequate hemoglobin level and intake of iron from dietary sources. In addition, this action may not eliminate the need for a transfusion and its related risks. The directed blood donation from a family member does not eliminate the risk of acquiring an infection.
An assistive personnel tells the nurse, "I am unable to find a large blood pressure cuff for a client who is obese. Can i just use the regular cuff if i can get it to stay on?" The nurse replies that taking the blood pressure of a MORBIDLY OBESE client with a REGULAR BP CUFF will result in a reading that is A. Inaudible B. Low C. Accurate D. High
D. High RATIONALE: bp cuffs come in various sizes, and the nurse realizes that the correct size cuff is necessary to obtain a reliable measurement. Bp readings may be falsely high if the cuff is too small for the client. A cuff that is too small will not yield an inaudible reading, a falsely low reading, or an accurate reading.
Which of the following should the nurse do FIRST when preparing to provide TRACHEOSTOMY CARE? A. Open all sterile supplies and solutions B. Stabilize the tracheostomy tube C. Don sterile gloves D. Perform hand hygiene
D. Perform hand hygiene RATIONALE: a basic principle of medical and surgical asepsis is thorough hand hygiene before any contact with clients or equipment. This reduces the risk of transmission of microbes from other areas of the facility to either the client or the equipment used for that client. Opening all the sterile supplies and solutions and donning sterile gloves is not the first action the nurse should perform. Stabilizing the tracheostomy tube is essential during all aspects of tracheostomy care, but it is not the first action the nurse should perform.
When assessing a client's HEART SOUNDS, the nurse hears a SCRATCHING SOUND during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and LEAN FORWARD. The nurse should DOCUMENT THE PRESENCE OF a(n) A. Ejection click B. Murmur C. Third heart sound D. Pericardial friction rub
D. Pericardial friction rub RATIONALE: a pericardial friction rub has a scratching, grating, or squeaking leathery quality. It tends to be high in frequency and best heard with the diaphragm of the stethoscope and with the client leaning forward. A pericardial friction rub is a sign of pericardial inflammation and may be heard with infective carditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. An ejection click is a high-pitched sound heard shortly after S1. It is associated with a dilated pulmonary artery or septal defects. A heart murmur has a swishing or whistling quality. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur may be a sign of valvular disease. A third heart sound is a low-pitched sound after the second heart sound. S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and those with heart disease, an S3 often indicates heart failure.
At a mobile screening clinic, a nurse is assessing a client who reports a history of HEART MURMUR due to AORTIC STENOSIS. To AUSCULTATE the AORTIC VALVE, the nurse should PLACE THE STETHOSCOPE at which location? A. Fifth intercostal space just medial to mid-clavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum
D. Second intercostal space to the right of the sternum RATIONALE: the aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward. The mitral valve is located in the fifth intercostal space just medial to the mid-clavicular line. The pulmonic valve is located in the second intercostal space to the left of the sternum. The tricuspid valve is located in the fifth intercostal space to the left of the sternum.
A nurse admits a client to a same-day surgery center for an exploratory LAPAROTOMY PROCEDURE this morning. The client's surgeon asks the nurse to witness the signing of the PRE-OP CONSENT form. In SIGNING THE FORM AS A WITNESS, the nurse AFFIRMS that A. The client fully understands the surgeon's explanation of the procedure B. The client has been informed about the risks and benefits of the procedure C. The nurse witnessed the surgeon's explanation of the procedure D. The signature on the pre-op consent form is the client's
D. The signature on the pre-op consent form is the client's RATIONALE: the nurse acts as a witness solely to attest that it is the client's signature on the pre-op consent form. It is the responsibility of the surgeon who will perform the procedure to inform the client of the risks and benefits, ensure that the client understands the explanation of the procedure, and obtain their consent.
A nurse is performing an ABDOMINAL ASSESSMENT of an adult client. Identify the correct sequence of steps used for this assessment. Auscultation Inspection Palpation Percussion
Inspection Auscultation Percussion Palpation RATIONALE: this sequence prevents altering the bowel sounds during an abdominal assessment. The appropriate sequence for any other assessment of an adult client is inspection, palpation, percussion, and auscultation.
