Exam 2 Chronic

A nurse using the principle-based approach to client care seeks to avoid causing harm to clients in all situations. What is this principle known as? A) Nonmaleficence B) Justice C) Fidelity D) Autonomy

A

A nurse who comments to coworkers at lunch that a client with a sexually transmitted infection has been sexually active in the community may be guilty of what tort? A. Slander B. Libel C. Fraud D. Assault

A

A client is very anxious before an invasive procedure. What CAM therapy would be most helpful to assist in decreasing anxiety? A) Meditation B) Chinese medicine C) Acupuncture D) Herbs

A

A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation

A

A Native American client informs the nurse that she practices shamanism. The nurse is aware that shamanism is best described as which of the following? A) Use of general healing techniques that involve plants, herbs, animals, ritual, ceremony, and purification by a medicine man or woman. B) system of postures, exercises, breathing techniques, and visualization that regulate balance C) The placement of thin, short, sterile needles at centers of nerve and vascular tissue along a meridian D) Adjustment of the spine to accomplish proper alignment and to release pressure on a nerve

A

A client admitted with Hodgkin disease has a handwritten prescription for vinblastine 3.7 mg intravenously (IV) weekly. The nurse interprets the prescription as vincristine 3.7 mg and administers the wrong medication. The client becomes neurovascularly compromised and has a fatal reaction to the medication. The client's family begins a litigious suit against the facility and the nurse's license is suspended by the board of nursing. In preparation for the lawsuit, the nurse meets with the nurse attorney to review the events. Which appropriate statement, if given by the nurse, indicates he has an understanding of the lawsuit? A) "I had a duty and it was my responsibility to get clarification before administering the medication, which I did not." B) "I checked the medication before giving it and literature states it is for Hodgkin disease." C) "I could not read the health care provider's handwriting, so I am not at fault." D) "I had a duty and it was my responsibility to double check the medication, which I did, yet this still happened."

A

A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared that I can't do it all and will get so sick that I will be a burden on my family." What is the nurse's best response? A) "Let's tackle it piece by piece. What is most scary to you?" B) "It is overwhelming, isn't it?" C) "Let's see how much you can learn today, so you are less nervous." D) "Many people live with diabetes and do it just fine."

A

A client informs a nurse practitioner that she takes the herb St. John's wort for symptoms of depression. The nurse recognizes herbal therapy as belonging to which complementary and alternative therapy (CAT) domain? A) Biologically based practices B) Energy medicine C) Mind-body medicine D) Manipulative practices

A

A client informs the nurse that he wants to discontinue his treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation? a) Let the client go after signing a document stating he is going against medical advice. b) Call the physician and get his discharge paper signed. c) Warn the client that he may not be able to access health care again. d) Restrain the client until his medical treatment is over.

A

A client newly diagnosed with congestive heart failure has a prescription for digoxin. The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care? A. The nurse withholds the medication and notifies the health care practitioner. B. The nurse administers the medication and reassesses the client after 30 minutes. C. The nurse withholds the medication, retakes the heart rate, and gives the medication at a later time. D. The nurse administers the medication after reviewing the client's serum potassium level.

A

A client refuses to have a pain medication administered by injection. A nurse says, "If you don't let me give you the shot, I will get help to hold you down and give it." With what crime might the nurse be charged? A) Assault B) Battery C) Negligence D) Defamation

A

A client states that his recent fall was caused by the fact that his scheduled antihypertensive medications were mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow? A) Document the client's claims and the events surrounding the alleged incident. B) Enlist support from nursing and non-nursing colleagues from the unit. C) Consult with the hospital's legal department as soon as possible. D) Consult with practice advisors from the state board of nursing.

A

A group of nurses working in a long-term care facility fails to keep the narcotic medications in a secure location. The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies and procedures. These failures may result in what type of disciplinary action? A) Action against the nurses' licenses B) Action against the facility's state license C) Action against the state regulating body D) Action against the pharmacist's license

A

A home care nurse is caring for a quadriplegic client who needs regular position changes and back massages. A gentleman identifying himself as a family friend inquires if he can be of any help to the family. What should be the nurse's response be? A) The nurse should ask the gentleman to talk to the family directly. B) The nurse should invite the gentleman to learn the caring techniques. C) The nurse should state that the family does not need any help. D) The nurse should refer the gentleman to the local social worker.

A

A lawsuit has been brought against a nurse for malpractice. The client fell and suffered a skull fracture, resulting in a longer hospital stay and need for rehabilitation. What does the description of the client and his injuries represent as proof of malpractice? A) Damages B) Causation C) Duty D) Breach of duty

A

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take FIRST? a. Assess the client's respiratory status b. Draw blood to assess the client's serum electrolytes c. Administer intravenous furosemide d. Ask the client about current medications

A

A nurse assesses a client with psychotic symptoms and determines that the client needs vest restraints. However,the client asks the nurse not to put on vest restraints. What would be the best nursing action? a) Contact the physician and obtain necessary orders. b) Apply wrist restraints instead of vest restraints. c) Apply restraints after giving a sedative. d) Restrain the client with vest restraints.

A

A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at GREATEST risk for the development of left-sided heart failure? a. A 36 year old woman with aortic stenosis b. A 42 year old man with pulmonary hypertension c. A 59 year old woman who smokes cigarettes daily d. A 70 year old man who had a cerebral vascular accident

A

A nurse cares for a client with right-sided HF. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. Weight is the best indication that you are gaining or losing fluid b. Daily weights will help us make sure that you're eating properly c. The hospital requires that all clients be weighed daily d. You need to lose weight to decrease the incidence of heart failure

A

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the BEST response by the nurse? a. I can stay if you would like to talk more about this b. You are lucky to have such a devoted daughter c. It is normal to feel as though you are a burden d. Would you like to meet with the chaplain?

A

A nurse hired to work in an ambulatory setting attends new employee orientation. The nurse never worked in ambulatory before and is concerned about the Scope and Standards of Practice for Professional Ambulatory Care Nursing. Which response, given by the nurse educator, would further explain the Scope and Standards of Practice for Professional Care Nursing to the new nurse? A )"The Scope and Standards of Practice for Professional Ambulatory Care Nursing deal with the professional obligations of a nurse working in the ambulatory setting." B) "The Scope and Standards of Practice for Professional Ambulatory Care Nursing sets the standards for the nursing supervisor to assess a nurse." C) "The Scope and Standards of Practice for Professional Ambulatory Care Nursing takes precedent over the facility's policies and procedures." D) "The Scope and Standards of Practice for Professional Ambulatory Care Nursing determines if a nurse is minimally competent to receive a license to practice as a nurse."

A

A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse? A) Obtain a medical order. B) Notify the family. C) Sedate the client. D) Get written consent.

A

A nurse is caring for a patient who has crippling rheumatoid arthritis. Which nursing intervention best represents the use of integrative care? A) The nurse administers naproxen and uses guided imagery to take the patient's mind off the pain. B) The nurse prepares the patient's health care provider-approved herbal tea and uses meditation to relax the patient prior to bed. C) The nurse administers naproxen and performs prescribed range-of-motion exercises. D) The nurse arranges for acupuncture for the patient and designs a menu high in omega-3 fatty acids.

A

A nurse is providing client care in a hospital setting. Who has full legal responsibility and accountability for the nurse's actions? A) The nurse B) The head nurse C) The physician D) The hospital

A

A nurse is providing teaching for a client who has a new prescription for metformin. Which of the following findings should the nurse tell the patient to report as an adverse effect of metformin? a. Somnolence b. Constipation c. Fluid Retention d. Weight Gain

A

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. Avoid using salt substitutes b. Take your medication with food c. Avoid using aspirin-containing products d. Check your pulse daily

A

A nurse is using a technique that involves the five senses to visualize recovering from an upcoming surgical procedure.What type of technique is the nurse teaching the client to use? A) Guided imagery B) Yoga C) Prayer D) Aromatherapy

A

A nurse manager who works in a hospital setting is researching the use of energy healing to use as an integrative care practice. Which patient would be the best candidate for this type of CHA? A) A patient who is anxious about residual pain from cervical spinal surgery B) A patient who is experiencing abdominal discomfort C) A patient who has chronic pain from diabetes D) A patient who has frequent cluster headaches

A

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law? A) The Good Samaritan law will provide legal immunity to the nurse. B) The Good Samaritan law is not applicable to health care workers. C) The Good Samaritan law will provide absolute exemption from prosecution. D) The Good Samaritan law will not protect the nurse because she did not accept compensation.

A

A nurse working on a busy medical-surgical unit does not take the vital signs of client who is preparing for discharge but instead documents the same vital signs obtained for this client earlier in the morning. For which tort would the nurse be potentially liable? A. Fraud B. False imprisonment C. Battery D. Assault

A

A physician is called to see a client with angina. During the visit, the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation? A. The nurse should ask the physician to come back and write the order. B. The nurse should write the order and implement it. C. The nurse should inform the client of the change in medication. D. The nurse should remind the physician later to write the work order.

A

Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement? A. "The rules made by the board of nursing don't reflect my practice." B. "The board of nursing exists to protect the safety of the public." C. "The board of nursing is established by state legislation." D. "Board of nursing rules keep unlicensed people from practicing nursing."

A

After having an abortion, a patient tells the visiting nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." She then talks with her priest about this feeling of guilt. Which evaluation statement shows a solution to the problem? a. patient states "I wish I had talked with the priest sooner. I now know God has forgiven me, and even my mother understands" b. patient has slept from 10 pm to 6 am for three consecutive nights without medication c. patient has developed mutually caring relationships with two women and one man d. patient has identified several spiritual beliefs that give purpose to her life

A

After reporting to work for a night shift, the nurse learns that the unit is understaffed because two RNs called out sick. As a result, each nurse on the unit must provide care for four acute clients in addition to the nurse's regular clients. Which statement is true for this nurse when working in understaffed circumstances? A. The nurse is legally held to the same standards of care as when staffing levels are normal. B. Understaffing constitutes an extenuating circumstance that creates a temporarily lower expectation for care for the nurse. C. The nurse must document that float staff, nurses on overtime, and part-time staff were contacted in an effort to fill the gaps in care. D. The nurse is legally obliged to refuse to provide care when understaffing creates the potential for unsafe conditions.

A

An HIV-positive client discovers that his name is published in a research report on HIV care prepared by his nurse. He is hurt and files a lawsuit against her. Which offense has the nurse committed? A) Invasion of privacy B) Unintentional tort C) Negligence of duty D) Defamation of client

A

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor? A. Battery B. Assault C. Fraud D. Defamation of character

A

An attorney is representing a patient's family who is suing a nurse for wrongful death. the attorney calls the nurse and ask to talk about the case to obtain a better understanding of the nurse's action. How should the nurse respond? A. "I'm sorry, but I can't talk with you; You have to contact my attorney." B. " I will answer your questions so you understand how the situation occurred." C. " I hope I won't leave blamed for the death because it was so busy that day." D. " first tell me why you were doing this to me. this could run my career!"

A

During a client interview, the client tells the nurse about using ginkgo biloba to improve memory. When reviewing the client's medication history, which medication if used by the client would be a cause for concern? A) Warfarin B) Acetaminophen C) Azithromycin D) Guaifenesin

A

During the admission assessment of a female client age 40 years with a suspected mandibular fracture, the client discloses to the nurse that her injury came as a result of her husband hitting her. Which action should the nurse prioritize when responding to this disclosure? A) Reporting the abuse to the appropriate authorities B) Ensuring the client's statement is confirmed by another nurse C) Informing the client of her right to keep this information private D) Performing an assessment to confirm the client's statement

A

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave her current position on a medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which of the following processes of credentialing? A)Certification B)Licensure C)Accreditation D)Validation

A

How will the nurse evaluate the level of glycemic control for a client with diabetes whose laboratory values include a fasting blood glucose level of 91 mg/dL and an A1C of 8.2%? A. The client's glucose control for the past 24 hours has been good but the overall control is poor. B. The client's glucose control for the past 24 hours has been poor but the overall control is good C. The values indicate that the client has poorly managed his or her disease D. The values indicate that the client has managed his or her disease well

A

Nurses are occasionally asked to witness a testator's (person who makes the will) signing of a will. Which guideline is true regarding a nurse's role in witnessing a testator's signature? A. Witnesses to a signature do not need to read the will. B. Witnesses do not need to observe the signing of the will and can sign it at a later time. C. A beneficiary to a will is allowed to act as a witness. D. A single witness is sufficient for a will.

A

The imbalance of which of the following can by the result of stress, lifestyle, and improper diet? A) Doshas B) Qi C) Chakras D) Aura

A

The nurse attempts to notify a health care provider about a client's elevated temperature, but does not get a response. Which statement, if documented by the nurse, would indicate that the nurse is following proper protocol for nursing documentation? A) 1300: Client temperature elevated. Telephoned health care provider's service 3 times without a response. Tepid sponge bath given and nursing supervisor notified. B) 1300: Client temperature elevated. Health care provider paged, but did not respond. Administered Tylenol without an order because I knew this health care provider does not return calls. C) 1300: Client temperature elevated. Telephoned health care provider's service several times with no response. Will notify nursing supervisor during rounds. D) 1300: Client temperature elevated. Telephoned health care provider 3 times. As usual, health care provider did not respond.

A

What types of exercise will the nurse recommend for the client with diabetic retinopathy? A. Non-weight-beating activities such as swimming B. Weight-bearing activities such as a jogging C. Gradually increasing aerobic and resistance exercises D. Weight training and heavy lifting

A

The nurse educator is presenting a lecture on the Occupational Safety and Health Act. Which situations, if identified by the nursing staff, would indicate to the educator that the staff understands which actions about the Occupational Safety and Health Act? A) Helps reduce workforce injuries and illness in the workplace B) Requires nurses to report abuse of infants, children, and adults of all ages C) Acts as an information clearing house for nurses who engage in unprofessional conduct D) Protects nurses who are recovering from drug or alcohol addiction or have communicable diseases

A

The nurse fails to contact the physician regarding a client who had an open-reduction internal fixation of the tibia and has experienced increasing leg pain (unrelieved by pain medication) for the past 4 hours. Which element of liability has been violated? A) Breach of duty B) Damages C) Causation D) Duty

A

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A) A 26 year old with type 1 diabetes whose insulin pump is beeping "occlusion." B) A 30 year old with type 1 diabetes who is reporting thirst. C) A 40 year old with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L). D) A 50 year old with type 2 diabetes with a blood pressure of 150/90 mm Hg.

A

The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning? A. Digoxin therapy daily. B. Daily metoprolol. C. Furosemide twice daily. D. Currently taking an antacid for upset stomach.

A

The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case? A. Breach of duty B. Causation C. Damages D. Duty

A

The nurse reports a nursing colleague on the unit who is lethargic and verbally responding in a slow manner. What is this an example of? A) Whistle-blowing B) Collective bargaining C) Delegating nursing care D) Ensuring adequate staffing

A

The nursing faculty is lecturing on unintentional and intentional torts. The faculty asks a nursing student to provide an example of an unintentional tort. Which example, if provided by the student, would indicate the student has a clear understanding of torts? A) A nurse gives a medication and client has an adverse reaction. B) Nurses are in the elevator discussing a client's laboratory values. C) A nurse is threatening to restrain a client if he does not stop talking. D) A nurse is telling a client he cannot leave the hospital until he pays his bill.

A

The nursing instructor is discussing alternative therapy with a group of students. She explains that living organisms are "continuously connecting and interacting with their environment." Furthermore, the connecting and interacting signifies that the human body is a unified dynamic whole. The instructor is describing what theory to the students? A) Holism perspective B) Integrative perspective C) Allopathic perspective D) Medical system perspective

A

The nursing student asks the nurse for an example of a "never event." Which example provided by the nurse bestanswers the nursing student's question? A) The client scheduled for a cholecystectomy has a total abdominal hysterectomy. B) The client receives preoperative medication before signing the informed consent. C) The client receives a medication and develops a rash on the trunk of the body, itching, and dyspnea. D) The client fails to receive a regularly scheduled medication.

A

What action will the nurse advise to prevent harm for a client with diabetes who has a 3-cm callus on the ball of the right foot? A) "Make an appointment with your podiatrist as soon as possible." B) "Make an appointment with a pedicurist and have them cut or file off the callus." C) "Soak your feet nightly in warm water and peel of a little of the callus every day." D) "Apply an over-the-counter callus-dissolving pad and follow the package directions."

A

What does the nurse suspect when assessment of a client with HF reveals pulses that alternate in strength? A. Pulses alternans B. Pulses paradoxus C. Orthostatic hypotension D. Angina

A

What early sign of left ventricular failure is a client most likely to report to the nurse? A. Nocturnal coughing B. Swollen legs C. Weight gain D. Nocturia

A

What governing body has the authority to revoke or suspend a nurse's license? A. The State Board of Nurse Examiners B. The employing health care institution C. The National League for Nursing D. The Supreme Court

A

What is the BEST action for a nurse to take to PREVENT HARM when a client with diabetes, who just reviewed a primal dose of regular insulin, is picked up by transportation to the radiation department for a scheduled x-ray before she has a chance to eat her lunch? A. Calling the radiation department and rescheduling the x-ray B. Sending the client's lunch with her to the radiation department C. Administering glucagon by the intramuscular route immediately D. Reminding the transporter that this client must be seen first in the radiation department

A

What is the nurse's best response when a client with diabetes who is being treated for hypoglycemic asks why people without diabetes don't become severely hypoglycemic even after fasting for 8 hours? A) In a person without diabetes, fasting for 8 hours converts proteins into glucose (gluconeogenesis) so that hyperglycemia develops rather than hypoglycemia. B) In a person without diabetes, the secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage sites (glycogenolysis). C) Normal metabolism is so slow when a person without diabetes fasts that blood glucose does not enter cells to be used for energy. As a result, hypoglycemia does not occur. D) Lipolysis (fat breakdown) in fat stores occurs faster in the nondiabetic person, which converts fatty acids into glucose to maintain blood glucose levels.

A

When the nurse inserts an ordered urinary catheter into the client's urethra after the client has refused the procedure, and then the client suffers an injury, the client may sue the nurse for which type of tort? A) Battery B) Assault C) Invasion of privacy D) Dereliction of duty

A

When the nurse reports for duty, she finds out her neighbor is admitted to one of units in her facility. The nurse asks a coworker about the neighbor's condition. The coworker is uncomfortable with the nurse's request and confers with the charge nurse. The charge nurse informs the coworker of which potential tort violation she could be charged with if she honors the nurse's request for client information? a) Invasion of privacy b) Assault c) Defamation of character d) Negligence

A

Which assessment finding will the nurse expect in a client with diabetes who has peripheral neuropathy of the motor neurons? A. Muscle weakness B. Orthostatic hypotension C. Absence of feeling in the feet D. Increased risk for myocardial infarction

A

Which complication is a client at most risk for when the nurse notes that excessive fluid was seen in the pericardial cavity on echocardiogram? A. Cardiac tamponade B. Pericardial friction rub C. Systemic emboli D. Splinter hemorrhages

A

Which instruction would the nurse give the assistive personnel (AP) who is helping a client with HP and excessive aldosterone secretion? A. Restrict the client's fluids to 2 L/day and keep accurate intake and output. B. Severely restrict fluids to 500 mL of fluid plus the client's urine output from the past 24 hours. C. Give the client as much water as he or she wants to prevent dehydration. D. Frequently offer the client ice chips and moistened mouth swabs and limit fluids to 1 L/day.

A

Which is the most important role of the nurse in using complementary and alternative therapies? A) Educating the public about safety and effectiveness B) Providing nutrition supplements for weight gain C) Administering herbal supplements for anxiety D) Practicing guided imagery prior to surgery

A

Which of the following aspects of nursing would be most likely defined by legislation at a state level? A) The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs). B) The criteria that a nurse must consider when delegating tasks to unlicensed care providers. C) The criteria that clients must meet in order to qualify for Medicare or Medicaid. D) The process that nurses must follow when handling and administering medications.

A

Which of the following best describes voluntary standards? A) Voluntary standards are guidelines for peer review, guided by the public's expectation of nursing. B) Voluntary standards set requirements for licensure and nursing education. C) Voluntary standards meet criteria for recognition, specified area of practice. D) Voluntary standards determine violations for discipline and who may practice.

A

Which of the following complementary and alternative therapies is based on the "Law of Minimal Dose"? A) Homeopathy B) Traditional Chinese C) qi Gong D) Ayurveda

A

Which of the following complementary and alternative therapies is based on the belief of supporting the body while the symptoms are allowed to run their course. A) homeopathy B) qi Gong C) traditional Chinese medicine D) Ayurveda

A

Which of the following considerations should a nurse prioritize surrounding the use of herbs and supplements by a client? A) Potential interactions with drugs B) The client's cultural background and beliefs C) The client's previous use of herbal supplements D) Pharmacological alternatives to herbs and supplements

A

Which of the following would be the least consistent as a reason for the use of complementary and alternative medicine(CAM)? A) Increasing numbers of acute conditions B) Dissatisfaction with conventional medicine C) Difficulty meeting rising health care costs D) Growth of culturally diverse groups

A

Which precaution is a priority for the nurse to teach a client prescribed dulaglutide to PREVENT HARM? A. Only take the drug once weekly B. Do not drink alcohol when taking this drug C. Take this drug right before or with the first bite of a meal D. Report any genital itching to your diabetes health care provider immediately

A

Which precaution is a priority for the nurse to teach a client prescribed semaglutide to prevent harm? A. Only take this drug once weekly B. Report any vision changes immediately C. Do not mix in the same syringe with insulin D. This drug can only be given by a health care professional

A

Which question would be appropriate for the F in the FICA spiritual assessment tool? A) "Do you consider yourself a spiritual person?" B) "Are you actively involved with a church community?" C) "Do you use your church family for support?" D) "How would you like me to address this issue in your health care?"

A

Which statement by a client indicates to the nurse correct understanding of what to do when the sensations of hunger and shakiness occur? A) "I will eat three graham crackers." B) "I will drink a glass of water." C) "I will sit down and rest." D) "I will give myself a dose of glucagon."

A

Which statement made by a client who is learning about self-injection of insulin indicates to the nurse that clarification is needed about injection site selection and rotation? A) "The abdominal site is best because it is closest to the pancreas." B) "I can reach my thigh best, so I will use different areas of the same thigh." C) "If I change my injection site from the thigh to an arm, the inulin absorption may be different." D) "By rotating sites within one area, my chance of having skin changes is less."

A

Which urgent intervention is required when the nurse receives the results of diagnostic testing for a client with aerobic stenosis and discovers that the surface area of the valve is less than 1 cm? A. Surgical aortic heart valve replacement B. Aortic valvuloplasty in the cardiac catheterization laboratory C. Physical therapy to create an individualized exercise program D. Therapy with drugs that will increase myocardial contractility

A

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure b. Document this as a normal finding c. Call the primary health care provider immediately d. Transfer the client to the intensive care unit

A

While walking down the hall, a nurse manager overhears a staff member telling a client, "If you don't stay in this chair and stop wandering, I'm going to tie you to it." The nurse manager pulls the staff member aside and discusses what was said. The nurse manager intervenes because the staff member's statement is which type of tort? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

A

Why is it important to obtain information from a client related to the use of herbal supplements during a nursing assessment? A) Some herbs or supplements may interact with a client's prescribed medications. B) Nurses have special knowledge related to the use of herbs and supplements. C) Some herbs or supplements require a special diet. D) The herb or supplement may need to be acquired from another country

A

Which health problems that are complications of chronic hyperglycemia will the nurse reinforce to the client with diabetes could be delayed or prevented with long-term good glucose control? SATA A. Amputation B. Blindness C. Chronic Kidney disease D. Heart attack E. erectile dysfunction F. Stroke

A, B, C, D, E, F

A nurse caring for a patient who is in pain following abdominal surgery investigates the use of CAT for pain. Which of the following modalities could be used to relieve this patients pain? Select all that apply A) massage B) acupuncture C) guided imagery D) Ayurveda E) yoga F) shamanism

A, B, C

A nurse is preparing a presentation for a group of staff nurses about spirituality and the importance of meeting clients' spiritual needs. As part the presentation, the nurse plans to address the major religious groups. Which characteristic would the nurse identify as being common to the major religions? Select all that apply. A) Involvement of a sacred word or scripture B) Ideas related to after death C) Ethical code for right and wrong D) Absence of a source of power or authority E) An identity as a group

A, B, C, E

A nurse is conducting a spiritual assessment on a client recently admitted to the hospital unit. Which questions would be appropriate to ask the client about his religious and spiritual practices? Select all that apply. A) "Is religion a significant part of your life?" B) "Are there any spiritual practices that you would like to continue while hospitalized?" C) "You would like the priest to come and visit you, right?" D) "Does the present situation interfere with any spiritual or religious practice?"

A, B, D

A nurse is educating staff members about the importance of meeting the spiritual needs of clients on the unit. What spiritual needs should be met in the delivery of care? Select all that apply. A) need for meaning and purpose B) need for love and relatedness C) need for comfort and money D) need for forgiveness E) need for complete health and freedom

A, B, D

Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? (SATA) A. Gluconeogenesis B. Glycogenesis C. Glycogenolysis D. Ketogenesis E. Lipogenesis F. Lipolysis

A, C

The nurse's client states that his pastor is coming in a few hours to pray with him and offer sacrament. The nurse plans to do the following things in preparation for this. Select all that apply. A) Clear the bedside table; cover with clean towel. B) Complete your work so you may join them. C) Have a chair available near the bed. D) Clear the room of unnecessary items. E) Keep the bed curtains open so as to allow others to join in prayer

A, C, D

For which situations will the nurse teach a client to perform urine ketone testing? A. Anytime he or she is acutely ill or severely stressed B. When blood glucose levels are above 200 mg/dL C. When symptoms of diabetic ketoacidosis (DKA) are present D. While participating in a weight-loss program E. Before engaging in strenuous exercise F. After eating citrus fruit of drinking alcohol

A, D, E

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension

A,B,C

A nurse is formulating diagnoses for patients in a hospice program who are experiencing spiritual distress. In which diagnoses is spiritual distress the etiology of another problem? Select all that apply. a. ineffective individual coping related to loss of religion as a major support in life b. powerlessness related to feeling unprepared for death and the afterlife experience c. self-esteem disturbance related to failure to reconcile illness with spiritual beliefs d. risk for impaired religiosity related to inability to attend church as usual e. spiritual distress related to fear of dying alone f. impaired religiosity related to inability to exercise reliance on spiritual beliefs

A,B,C

The nurse is slightly overweight and decides to take a holistic approach to losing weight. The nurse does which of the following? Select all that apply. A) Eliminates cola drinks B) Decreases refined sugar C) Avoids foods with preservatives D) Adopts a vegetarian diet E) Substitutes aspartame for sugar

A,B,C,D

A client comes to a clinic for a checkup. The clinic practices integrative care. During the visit, the client reports a "runny nose" accompanied by sinus pressure, cough and mild fever. The client states, "I think I have a cold." Which intervention would the nurse include for this client as part of integrative care? Select all that apply. A) Using an over-the-counter nasal decongestant spray B) Drinking lots of fluids throughout the day C) Undergoing acupressure to appropriate sites for nasal congestion relief D) Practicing good hand washing to prevent the risk for transmission E) Using echinacea or zinc for prevention of colds

A,B,C,D,E

Which assessment findings in a 33-year-old female client indicate to the nurse that she has an increased risk for type 2 diabetes? SATA A. A1C is 5.8% B. Weight is 25 lb. above ideal C. Has a 10 lb. baby 2 years ago D. Has irritable bowel syndrome with constipation E. Fasting blood glucose level is 119 mg/dL F. Mother, sister, and maternal grandmother all have type 2 diabetes

A,B,C,E,F

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (SATA) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue

A,B,C,F

A nurse cares for patients in a chiropractic office. What patient education might this nurse perform? Select all that apply. A) Applying heat or ice to an extremity B) Explaining the use of electrical stimulation C) Teaching a patient relaxation techniques D) Teaching a patient about a prescription E) Explaining an invasive procedure to a patient F) Teaching about dietary supplements

A,B,C,F

A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at GREATEST risk for the development of acute pericarditis? (SATA) a. 36 year old woman with systemic lupus erythematosus (SLE) b. 42 year old man recovering from coronary artery bypass graft surgery c. 59 year old woman recovering from a hysterectomy d. 80 year old man with a bacterial infection of the respiratory tract e. 88 year old woman with a stage III sacral ulcer

A,B,D

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

A,B,D

A nurse prepares to discharge a client who has heart failure. What questions would the nurse ask to ensure this client's safety prior to discharging home? (select all that apply) a. Are your bedroom and bathroom on the first floor? b. What social support do you have at home? c. Will you be able to afford your oxygen therapy? d. What spiritual beliefs may impact your recovery? e. Are you able to accurately weigh yourself at home?

A,B,D

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d. "What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?"

A,B,D

With which signs and symptoms will the nurse teach a client to take action to PREVENT HARM as indicators of mild hypoglycemia? SATA A. Headache B. Weakness C. Cold, clammy skin D. Irritability E. Pallor F. Tachycardia

A,B,D

Which are potential benefits of a client receiving the drug digoxin? A. Reduced heart rate B. Increased contractility C. Venous vasodilation D. Slowed conduction through the AV node E. Inhibition of sympathetic activity with enhanced parasympathetic activity F. Enhanced renal excretion of sodium and water

A,B,D,E

A nurse works for a health care provider who practices the naturopathic system of medicine. What is the focus of nursing actions based on this type of medical practice? Select all that apply. A) Treating the symptoms of the disease B) Providing patient education C) Focusing on treating individual body systems D) Making appropriate interventions to prevent illness E) Believing in the healing power of nature F) Encouraging patients to take responsibility for their own health

A,B,D,E,F

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (SATA) a. Pulmonary crackles b. Confusion c. Pulmonary hypotension d. Dependent edema e. Cough that worsens at night f. Jugular venous distension

A,B,E

According to HIPPA regulations, which of the following is a client right regarding the client's medical record? Select all that apply. A) To see the health record B) To copy the health record C) To make additions to the health record D) To cross out sections of the health record E) To restrict certain disclosures of the health record

A,B,E

A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (SATA) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria

A,B,E,F

A nurse collaborates with assistive personnel to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (SATA) a. Reposition the client every 2 hours b. Teach the client to perform deep-breathing exercises c. Accurately record intake and output d. Use the same scale to weigh the client each morning e. Place the client on oxygen if the client becomes short of breath

A,C,D

The nurse is concerned about a potential malpractice or negligence lawsuit regarding a client that was cared for on the unit. What specific elements must be established to prove that malpractice or negligence has occurred in this client? (Select all that apply.) A) Causation B) Misrepresentation C) Damages D) Breach of duty E) Duty F) Breach of confidentiality

A,C,D,E

Which assessment findings would the nurse expect to find in a client with left heart failure? Select all that apply. A. Wheezes or crackles B. Jugular vein distention C. S3 heart sound D. Paroxysmal nocturnal dyspnea E. Ascites F. Oliguria during the day

A,C,D,F

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What are examples of legal safeguards for the nurse? Select all that apply. A) The nurse obtains informed consent from a client to perform a procedure. B) The physician is responsible for administration of a wrongly prescribed medication. C) The nurse educates the client about The Patient Care Partnership. D) The nurse executes physician orders without questioning them. E) The nurse documents all client care in a timely manner. F) The nurse claims management is responsible for inadequate staffing leading to negligence

A,C,E

Which early symptoms indicate to the nurse that a client's HF is getting worse and pulmonary edema is developing? Select all that apply. A. Crackles in the lung bases B. Frothy, blood-tinged sputum C. Dyspnea at rest D. Cyanosis E. Disorientation F. Level of crackles rises higher in the lungs

A,C,E

Which of the following statements accurately describes an aspect of the credentialing process used in nursing practice?Select all that apply. A) Credentialing refers to the way in which professional competence is ensured and maintained. B) Accreditation is the process by which the state determines that a person meets minimum requirements to practice nursing. C) Certification grants recognition in a specified practice area to people who meet certain criteria. D) Legal accreditation of a school preparing nursing personnel by the state Board of Nursing is voluntary. E) Once earned, a license to practice is a property right and may not be revoked without due process.

A,C,E

Which signs and symptoms would the nurse expect to assess when a client is diagnosed with aortic stenosis? Select all that apply. A. Dyspnea on exertion B. Atypical chest pain C. Angina D. Hemoptysis E. Harsh, systolic crescendo-decrescendo murmur F. Orthopnea

A,C,E,F

Which situations or conditions will the nurse teach a client with diabetes are common causes of hypoglycemia? SATA A. Too much insulin taken compared with food intake B. Increased food intake especially after missed or delayed meals C. Insulin injected at the wrong time relative to food intake and physical activity D. Decreased insulin sensitivity as a result of regular exercise and weight loss E. Decreased insulin clearance from progressive kidney failure F. Decreased liver glucose production after alcohol ingestion

A,C,E,F

Newly hired nurses in a busy suburban hospital are required to read the state Nurse Practice Act as part of their training. Which topics are covered by this act? Select all that apply. A. Violations that may result in disciplinary action B. Clinical procedures C. Medication administration D. Scope of practice E. Delegation policies F. Medicare reimbursement

A,D

A nurse explains the informed consent form to a client who is scheduled for heart bypass surgery. Which of the following are elements of this consent form? Select all that apply. A) Disclosure B) Organ donation C) DNR orders D) Comprehension E) Competence

A,D,E

After teaching a client with congestive hear failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a CORRECT understanding of the teaching related to nutritional intake. (SATA) a. I'll read the nutritional labels on food items for salt content b. I will drink at least 3 L of water each day c. Using salt in moderation will reduce the workload of my heart d. I will eat oatmeal for breakfast instead of ham and eggs e. Substituting fresh vegetables for canned ones will lower my salt intake f. Salt substitutes are a good way to cut down on sodium in my diet

A,D,E

Which of the following nursing actions would be considered a violation of HIPPA regulations? Select all that apply. A) A nurse ambulates a client through a hospital hallway in a hospital gown that is open in the back. B) A nurse shoves a confused, bedridden client into bed after he made several attempts to get up. C) A nurse inadvertently administers the wrong dose of morphine to a client in the ICU. D) A nurse uses a client's chart as a sample teaching case without changing the client's name. E) A nurse reports the condition of a client to the client's employer.

A,D,E

Which new-onset symptoms will the nurse instruct a client with diabetes who is prescribed to take the sodium-glucose cotransport inhibitor, empagliflozin, to report to the diabetes health care provider to prevent harm? (Select all that apply.) A) Muscle weakness and dizziness on standing B) Redness and tenderness at the injection site C) Rapid weight gain and shortness of breath D) Redness and tenderness of the perineum E) Sensations of hunger, tremors, sweating, and confusion F) Pain and burning on urination

A,D,E,F

Which drugs would the nurse prepare to administer to a client with HF who has developed pulmonary edema? Select all that apply. A. Nitroglycerin sublingual B. Lorazepam IV C. Oxygen at 1 L/min nasal canula D. Furosemide IV E. Metoprolol IV F. Nitroglycerin IV

A,D,F

Which interventions would the nurse expect to include in the care of a client with pulmonary edema caused by HF? Select all that apply. A. Sodium restriction B. Fluid restriction C. Administration of potassium supplement D. Position client in semi-Fowler or high-Fowler E. Weekly weight monitoring F. Administration of loop diuretics

A,D,F

Which issues regarding diabetes management will the nurse consider delaying to teach about to a client with newly diagnosed type 1 diabetes until after the initial phase? SATA A. Discussing exactly what causes type 1 diabetes B. Preparing and administering insulin C. Implementing sick-day management rules D. Recognizing indications of hypoglycemia and hyperglycemia E. Explaining the risk for passing on type 1 diabetes to one's children F. Monitoring urine ketone levels

A,E,F

A client age 46 years has been diagnosed with cancer. He has met with the oncologist and is now weighing his options to undergo chemotherapy or radiation as his treatment. This client is utilizing which ethical principle in making his decision? A. Beneficence B. Autonomy C. Justice D. Confidentiality

B

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" What is the most appropriate response made by the nurse? A) "We have it on file here, so any hospital can call and get a copy." B) "Take it with you. It is recognized universally in the United States." C) "A living will can only be used in the state it was created in." D) "As long as your family knows your medical wishes, you will not need it."

B

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met? A. Duty B. Breach of duty C. Proximate cause D. Damages

B

A client has a prescription for amoxicillin 500 mg P.O. every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops complications and has an increased length of stay. The client files a lawsuit against the facility and the nurse. Which legal action has the nurse's attorney identified that meets the criteria for the client's lawsuit? A. Negligence B. Malpractice C. Assault D. Battery

B

A client inquires about the use of herbal therapy. Which statement by the nurse is most accurate? A) "All herbs are equal in purity, so purchase the cheapest brand." B) "Herbs can have side effects and can interact with prescription medications." C) "Be sure to pay attention to the packaging's therapeutic and prevention information." D) "It is best if you select a licensed herbalist as a practitioner."

B

A client who has undergone resection of the intestine is on a liquid diet with a nasogastric tube in place. He refuses the food tray with regular food that comes to his room and insists that a physician be called. The nurse insists that it is the right food and makes the client take it. The client develops complications and has to be re-operated upon. How is negligence determined in this situation? A) The nurse did not call the physician when the client asked. B) The nurse did not realize the importance of the tube. C) The dietary department sent the wrong diet for the client. D) The nurse insisted the patient have the solid food.

B

A client with diabetes who now has chronic albuminuria asks the nurse how this change will affect his health. How will the nurse answer this question? A. "You will need to limit your intake of dietary albumin and other proteins to reduce the albuminuria." B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage." C. "Your risk for developing urinary tract infections is greatly increased, requiring the need to take daily antibiotics for prevention." D. "From now on you will need to limit your fluid intake to just 1 L daily and completely avoid caffeine to protect your kidneys."

B

A medical surgical client is in the radiology department. The client's cousin arrives on the medical surgical unit and asks to speak with the nurse caring for his cousin. The visitor asks the nurse to provide a brief outline of the client's illness. Which response, if given by the nurse, would demonstrate application of legal safeguard in her practice? A) "Do you have any identification proving you are related to the client?" B) "I cannot give you that information due to client confidentiality." C) "I'm busy right now, but can talk later." D) "I will call the client and ask his permission."

B

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. I sleep with four pillows at night b. My shoes fit really tight lately c. I wake up coughing every night d. I have trouble catching my breath

B

A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. Do you have trouble breathing or chest pain? b. Are you still able to walk upstairs without fatigue? c. Do you awake with breathlessness during the night? d. Do you have new-onset heaviness in your legs?

B

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

B

A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

B

A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

B

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the BEST response by the nurse? a. The prosthetic valve places you at greater risk for a heart attack b. Blood clots form more easily in artificial replacement valves c. The vein taken from your leg reduces circulation in the leg d. The surgery left a lot of small clots in your heart and lungs

B

A nurse comes across a screaming child in the park. The child was hit by a baseball bat, resulting in a swollen and reddened left arm. Any attempt to move the child's left arm results in the child screaming intensely. The nurse used two baseball bats to make a split, which she applied to the child's left arm. The child is transported to the hospital and later develops compartmental syndrome of the left arm. The nurse requests a meeting with the nurse attorney to discuss the possibility of being involved in a litigious suit by the child's family. After a review of the events, which important information will the attorney share with the nurse concerning the case? A) The nurse was negligent because the client developed compartmental syndrome because of her treatment at the scene. B) The nurse is protected by the Good Samaritan Act, which states the nurse may give emergency care using good judgment. C) The nurse does not fall under the Good Samaritan Act because it is apparent she was negligent in the care she rendered. D) The nurse should have waited for help because the Good Samaritan Act states the nurse is not obligated to assist.

B

A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next? A) Administer the medication based on the order B) Question the order for the medication C) Refuse to administer the medication D) Document concerns about the order

B

A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal ECG waves, indicating arterial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which of the following describes the nurse's legal liability? a) Slander b) Tort c) Defamation d) Felony

B

A nurse is overheard in the hospital cafeteria making false comments about a client. The nurse is guilty of: A) invasion of privacy B) slander C) libel D) assault.

B

A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? a. Use a soft-bristled toothbrush and avoid flossing b. Avoid large crowds and people who are sick c. Change positions slowly to avoid hypotension d. Check your heart rate before taking the medication

B

A nurse is providing teaching to a client who has type 2 diabetes and is starting repaglinide. Which of the following statements by the client indicates understanding of the administration of this medication? a. "I'll take this medication after I eat." b. "I'll take this medicine 30 min before I eat" c. I'll take this medicine just before I go to bed." d. "I'll take this medication at least one hour before I eat."

B

A nurse moves from Ohio to Missouri. Where can a copy of the Nurse Practice Act in Missouri be obtained? A) Ohio State Board of Nursing B) Missouri State Board of Nursing C) Federal government nursing guidelines D) National League for Nursing

B

A nurse observes another nurse place an unused dose of narcotics in their pocket. If caught, the nurse could be charged with which type of crime? A) tort B) felony C) misdemeanor D) negligence

B

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching? a. "Walk until you become short of breath, and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."

B

A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. Walk until you become short of breath, then walk back home b. Begin walking 200 feet a day three times a week c. Do not lift heavy weights for 6 months d. Eat plenty of protein to build your strength

B

A nurse who "unblocks" and "clears" congested areas of energy in a client's body to promote comfort is applying the phenomenon known as: A) Tactile manipulation B) Therapeutic Touch (TT) C) "Unruffling" touch D) Interpersonal touch

B

A nurse who is comfortable with one's own spirituality is caring for patients who need spiritual counseling. Which nursing action would be most appropriate for these patients? a. calling the patient's own spiritual adviser first b. asking whether the patient has a spiritual adviser the patient wishes to consult c. attempting to counsel the patient, if unsuccessfuld, making a referral to a spiritual adviser d. advising the patient and the spiritual adviser concerning health options and the best choices for the patient

B

A nurse working in a long-term care facility incorporates aromatherapy into her practice. For which patient would this nurse use the herb ginger? A) A patient who has insomnia B) A patient who has nausea C) A patient who has dementia D) A patient who has migraine headaches

B

A nursing student asked the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? A. Students are not responsible for their actions of negligence resulting in patient injury B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse C. Hospitals are exempt from liability for student negligence if the student nurses properly supervised by an instructor D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary

B

A student is preparing to graduate from nursing school and understands that professional regulations and laws that govern nursing practice are in place. These regulations and laws are in place for which reason? A)to ensure that enough new nurses are always available B) to protect the safety of the public C) to ensure that practicing nurses are of good moral standing to limit the number of nurses in practice

B

A student nurse is assisting an elderly patient to ambulate following hip replacement surgery, and the patient falls and reinjures the hip. Who is potentially responsible for the injury to this patient? A) The student nurse B) All of the above C) The nurse instructor D) The hospital

B

After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is MOST important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption b. Instruct the client to ask for assistance when rising from bed c. Collaborate with assistive personnel to bathe the client d. Monitor potassium levels and check for signs of hypokalemia

B

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for ADDITIONAL teaching? a. I'll be able to carry heavy loads after 6 months of rest b. I will have my teeth cleaned by my dentist in 2 weeks c. I must avoid eating foods high in vitamin K, like spinach d. I must use an electric razor instead of a straight razor to shave

B

For which client complication of diabetes will the nurse expect to administer glucagon intramuscularly? A. Diabetic retinopathy B. Severe hypoglycemia C. Diabetic ketoacidosis (DKA) D. Hyperglycemia-hyperosmolar state (HHS)

B

How will the nurse evaluate the level of glycemic control for a client with diabetes whose laboratory values include a fasting blood glucose level of 82 mg/dL (mmol/L) and an A1c of 5.9%? A) The values indicate that the client has poorly managed his or her disease. B) The values indicate that the client has managed his or her disease well. C) The client's glucose control for the past 24 hours has been good but the overall control is poor. D) The client's glucose control for the past 24 hours has been poor but the overall control is good.

B

How will the nurse modify insulin injection technique for a client who is 5 feet 10 inches tall and weighs 106 lb? A. Use a 6 mm needle and inject at a 90 degree angle B. Use a 6 mm needle and inject at a 45 degree angle C. Use a 12 mm needle and inject at a 90 degree angle D. Use a 12 mm needle and inject at a 45 degree angle

B

How will the nurse reply when a client with type 2 diabetes tells the nurse that he would like to have a 12-ounce glass of beer with supper but believes that is now impossible? A) "You can have a beer with a meal if you test yourself for hypoglycemia an hour later." B) "You can have a beer with a meal if you test yourself for hyperglycemia an hour later." C) "There are nonalcoholic beers available that you can substitute for a regular beer." D) "If you gave up dessert, you can still have one beer."

B

In comparison with licensure, which measures entry-level competence, what does certification validate? A) innocence of any disciplinary violation B) specialty knowledge and clinical judgment C) more than 10 years of nursing practice D) ability to practice in more than one area

B

Injuries related to lifting or transferring patients occur in the health care setting and may be considered a work-related injury. Which law was intended to reduce work-related injuries and illnesses? a) Americans with Disabilities Act of 1990 b) The Occupational Safety and Health Act of 1970 c) Title VII of the Civil Rights Act of 1964 d) The Health Care Quality Improvement Act of 1986

B

Review of a patient's record revealed that on one obtained informed consent for the heart surgery that was performed on the pt. which intentional tort was being committed? A. assault B. battery C. invasion of privacy D. false imprisonment

B

The client being admitted to the oncology unit conveys his wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in his best interest to obtain which document? A) Proof of health care power of attorney B) A living will C) A proxy directive D) A will

B

The client who is newly diagnosed with diabetes mellitus type 2 is concerned about eating products with sugar in them. What information does the nurse explain to the client regarding the use of sugar? A) Sugar assists with cellular absorption of nutrients. B) Excess sugar increases demand on the pancreas. C) Healthy amounts of sugar are usually consumed. D) Sugar increases natural bacterial flora in the GI tract.

B

The nurse caring for a Native American client plans care understanding that one belief of Native American healing practices is which of the following? A) Modern life facilitates healing agents. B) Healing takes time. C) Balancing yin and yang is important. D) Energy flows through meridians throughout the body.

B

The nurse is accused of malpractice by a client. List the order in which the steps of the litigation process will occur (use all options). 1) The basis for the claim is determined to be appropriate and timely with all elements of liability present. 2) All parties named as defendants (nurses, physicians, health care agency), as well as insurance companies and attorneys, work toward a fair settlement. 3) Trial takes place; both sides present their evidence and arguments. 4) The case is presented to a malpractice arbitration panel. The panel's decision is either accepted or rejected, in which case a complaint is filed in trial court. 5) Pretrial discovery activities occur: review of medical records and depositions of plaintiff, defendants, and witnesses. 6) The defendants contest allegations. A) 2, 3, 4, 1, 5, 3 B) 1, 2, 4, 6, 5, 3 C) 1, 2, 3, 4, 5, 6 D) 2, 6, 5, 3, 1, 4

B

The nurse is caring for a client who states, "No one can understand God." The nurse would document the client's spiritual belief as: A)atheist. B) agnostic C) theist D) holistic.

B

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A) "I may need this drug every other day according to lab values." B) "I need to take potassium supplements with this medication." C) "I will try my best not to use table salt on my food." D) "This medication will cause me to urinate more often."

B

The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What complications will the nurse suspect? A) pulmonary embolus B) renal infarction C) transient ischemic shock D) splenic infarction

B

The nurse is preparing to administer a medication ordered by the surgeon in a dose much higher than is recommended. Which action should the nurse take? a) Administer the medication in the usual dosage. b) Call the surgeon to clarify the order. c) Administer the medication as ordered and chartthe high dose. d) Administer the medication and stay with the client to observe for adverse reactions.

B

The nursing student is taking an examination on Nursing Ethics and Law. Which choice selected by the student would indicate to the nursing faculty that the student has a good understanding of negligence? a) The nurses assesses for collateral circulation (Allen's test) before performing an arterial blood gas (ABG). b) The nurse assesses distal pulses on a client three hours after a femoral arteriography. c) The nurse advises a visitor to avoid bringing fresh fruit to a client with neutropenia. d) The nurse auscultates breath sounds every 8 hours on a client receiving enteral feedings.

B

The student nurse tells her family about a client with AIDS that she cared for in clinical yesterday. Which tort has the student committed? A) Assault B) Invasion of privacy C) Slander D) Fraud

B

Two nurses are discussing a client's condition in an elevator full of visitors. With what crime might the nurses be charged? A) Defamation of character B) Invasion of privacy C) Unintentional negligence D) Intentional negligence

B

Two nurses meet at their home, where one of the nurses discusses a client who had been physically abused. The next day, the client is shifted to another nursing unit after a surgical procedure and becomes the care of the second nurse who had been part of the original discussion. NurseNo. 2 asks the client about the physical abuse. The client discovers that his original nurse revealed the information and is hurt. What would be the charges if the client files a suit? a) No charges are valid because Nurse No. 2 is also involved in client care. b) The nurses could be charged for slander. c) No charges are valid because the revelation took place in off-duty hours. d) The nurses could be charged for libel.

B

What is the definitive treatment for chronic constructive pericarditis? A. Pericardiocentesis B. Surgical removal of the pericardium C. Placement of a pericardial drain D. Creation of a pericardial window

B

What is the nurse's best action when finding that a client who has had diabetes for 15 years has decreased sensory perception in both feet? A) Testing the sensory perception of the client's hands B) Examining both feet for indications of injury C) Explaining to the client that peripheral neuropathy is now present D) Documenting the finding as the only action

B

What is the priority concept for a client who has heart failure? A. Gas exchange B. Perfusion C. Comfort D. Infection

B

What is the priority intervention when a client comes to the emergency department (ED) with extreme anxiety, tachycardia, struggling for air, and a moist cough productive of frothy and blood-tinged sputum? A. Prepare for endotracheal intubation and mechanical ventilation. B. Administer high-flow oxygen therapy by face mask. C. Prepare for continuous positive airway pressure ventilation. D. Apply a pulse oximeter and a cardiac monitor.

B

What problem does the nurse suspect when a client with well-controlled diabetes develops an unexpected increase in blood glucose level 2 days after surgery? A. Family bringing in food for client consumption B. Wound infection occurring before fever C. Response to interactions of newly prescribed drugs D. Progression of disease severity to type I diabetes

B

When a client has an ejection fraction of less than 30%, about which potential treatment does the nurse prepare to educate the client? A. Heart transplant B. Implantable cardioverter/defibrillator C. Ventricular reconstructive procedure D. Implanted mechanical pump

B

When making client rounds, the charge nurse observes which action by a staff nurse that would constitute battery? a) The staff nurse threatens to restrain the client if she did not take her medication. b) The elderly client refuses the intramuscular injection, but the staff nurse administered it. c) The nurse tells the client she cannot leave the hospital because she is seriously ill. d) While bathing a client behind pulled curtains, two nurses are discussing a different client.

B

When the client asks the nurse about the best method of diagnosing heart failure, what teaching would the nurse provide? A. Radionuclide studies B. Echocardiography C. Multigated acquisition (MUGA) scan D. Pulmonary artery catheter

B

Which action will the nurse recommend to a client with type 1 diabetes on insulin therapy who has been having a morning fasting blood glucose level o 160 mg/dL and is diagnosed with the "Somogyi phenomenon" to achieve better control? A. "Avoid eating any carbohydrate with your evening meal." B. "Eat a bedtimes snack containing equal amounts of protein and carbohydrates." C. "Inject the insulin into your arm rather than into the abdomen around the navel." D. "Take your evening insulin dose right before going to bed instead of at supper time."

B

Which action will the nurse teach a client with diabetes to perform self-monitoring of blood glucose (SMBG) levels to PREVENT HARM from blood-borne infections? A. Washing hands before beginning the test B. Not sharing the monitoring equipment with others C. Blotting away any excess blood from the strip D. Using gloves during monitoring

B

Which assessment action is a PRIORITY for the nurse to perform FIRST to PREVENT HARM for a client with diabetes whose blood osmolarity is 345 MOs/L? A. Checking skin turgor B. Measuring blood pressure C. Testing for ketones in the urine D. Checking the most recent serum electrolyte values

B

Which assessment finding in a client with long-standing diabetes will the nurse interpret as an early sign of diabetic nephropathy? A. Positive urine red blood cells B. Microalbuminuria C. Positive urine glucose D. Positive urine white blood cells

B

Which class of anti diabetic drug will the nurse hold for a client after an imaging test using contrast medium until adequate kidney function is established? A. Alpha-glucosidase inhibitors B. Biguanides C. Meglitinides D. Second-generation sulfonylureas

B

Which of the following is an example of certification? A) A graduate of a nursing education program who passes NCLEX-RN. B) A nurse who demonstrates advanced expertise in a content area of nursing through special testing. C) A hospital that meets the standards of the Joint Commission. D) An education program that meets standards of the National League for Nursing.

B

Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes to prevent harm? A) "Check your hands and feet weekly for chronic excessive sweating." B) "Change positions slowly when moving from sitting to standing." C) "Avoid drinking caffeine or caffeinated beverages." D) "Be sure to take your blood pressure drug daily."

B

Which priority information would the nurse be sure to provide for a client who is scheduled for mitral valve replacement with a xenograft valve? A. "You will need an individualized exercise program to develop collateral circulation." B. "You xenograft valve will need to be replaced in about 7 to 10 years." C. "You must take and record your temperature daily and watch for signs of rejection." D. "You will require frequent laboratory tests to monitor your coagulation status."

B

Which priority teaching would the nurse provide to a client with infective endocarditis who is scheduled for an invasive dental procedure? A. "Be sure to use your nitroglycerin whenever you experience chest pain." B. "Remind your health care provider to provide you with a prescription for prophylactic antibiotics." C. "Get up slowly after taking each dose of your antihypertensive medication." D. "Your health care provider will instruct you to have blood drawn to check your anticoagulation status."

B

Which response on blood glucose level dose the nurse expect to find a client with diabetes who is now receiving corticosteroid therapy for an acute inflammation? A. hypoglycemia B. hyperglycemia C. Ketoacidosis D. No specific change

B

Which situation is an example of battery that the nurse may experience while performing her duties at the healthcare facility? a) telling the client that he cannot leave the hospital b) performing a surgical procedure without getting consent c) taking the client's photographs without consent d) witnessing a procedure done on a client without his consent

B

Which specific action is a priority for the nurse to teach a client with diabetes who has peripheral neuropathy to prevent harm? A) "Wear a medical alert bracelet." B) "Never go barefoot." C) "Never reuse insulin syringes." D) "Drink at least 3 L of fluids daily."

B

Which statement by a client with heart failure indicates to the nurse the need for additional teaching? A. "If my heart feels like it's racing, I should call my health care provider." B. "I must weigh myself once a week and watch for signs of fluid retention." C. "I'll need periods of rest and activity and I should avoid activity after meals." D. "I'll need to consider and plan my activities for the day, and rest as needed."

B

Which statement made by the client with type 1 diabetes during nutritional counseling indicates t the nurse that her or she correctly understands his or her nutritional needs? A. "If I completely eliminate carbohydrates from my diet, I will not need to take insulin." B. "I will make certain that I eat at least 130 g of carbohydrate each day regardless of my activity level." C. "My intake of protein in terms of grams and calories should be the same as my intake of carbohydrates." D. "My intake of unsaturated fats in terms of grams and calories should be the same any intake of protein."

B

Which are proposed criteria for diagnosis of a client with acute pericarditis? Select all that apply. A. Chest pain that lasts longer than 3 months. B. Pericardial chest pain C. Presence of a pericardial friction rub D. New ST elevation in all ECG leads or PR-segment depression E. New or worsening pericardial effusion F. Hepatic engorgement

B,C,D,E

Which treatment best applies to the care of a client newly diagnosed with infective endocarditis? A. Long-term anticoagulant therapy with IV heparin followed by oral warfarin B. Hospitalization for initial IV antibiotic, followed by continued IV antibiotics at home C. Complete bedrest for the duration of the treatment with subcutaneous enoxaparin D. Administration of IV penicillin, followed by oral penicillin for 6 to 10 weeks

B

Which type of heart valvular disease does the nurse suspect when a client's assessment reveals pitting edema? A. Aortic valve stenosis and regurgitation B. Mitral valve stenosis and regurgitation C. Mitral valve prolapse D. Tricuspid valve prolapse

B

While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48 mg/dL. What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT dose of glucagon B. Immediately give the client 30 g of glucose orally C. Start an IV and administer a small amount of a concentrated dextrose solution D. Recheck the blood glucose level and call the Rapid Response team

B

While teaching about advance care planning, which fact is important for the nurse to share with a client who has been diagnosed with a terminal illness? A) The Patient Self-Determination Act of 1990 requires hospital clients to have an advance directive. B) A durable power of attorney for health care appoints an agent the person trusts to make decisions. C) Living wills provide specific instructions related to the client's personal property upon death. D) Advance directives must be completed 30 days prior to hospitalization in order to be valid.

B

Which hormones help prevent hypoglycemia? (SATA) A. Aldosterone B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon F. Insulin G. Norepinephrine H. Proinsulin

B, C, D, E, G

A nursing student administers an overdose of a narcotic to a client and the client arrests. When discussing the incident with nursing faculty, which statements, if made by the student, indicate the need for further teaching? A) "I realize that I am held to the same standards as a registered nurse." B) "I cannot be held liable because this is only my second time at this facility." C) "I should have informed you that I felt unprepared for my assignment." D) "I am glad I am a student because nursing faculty will be blamed, not me." E) "I have also put the nursing faculty at risk with my action."

B, D

Which nursing actions are appropriate when caring for a client who participates in the Hindu religion? Select all that apply. A) Accommodate the practice of obligatory prayers and fasting on holy days. B) Consider the client to be open to new ideas in health care practices. C) Accept that women are not allowed to make independent decisions. D) Anticipate many dietary restrictions, conforming to individual sect doctrine. E) Accommodate certain rites to be practiced following death. F) Learn rituals marking life changes, birth, puberty, initiation rites, and death.

B, D, E

Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? (SATA) A. "Avoid all dietary carbohydrate and fat." B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." D. "Be sure to take your anti diabetes drug right before your engage in any type of exercise." E. "Keep your feet warm in cold weather by using either a hot water bottle or a heating pad." F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing flip-flops when you are at home."

B,C

Which of the following is an area of potential liability for the nurse? Select all that apply. a) The nurse notifies the physician of the client's adverse reaction to a medication. b) The nurse documents that the client's blood pressure has increased from 118/72 to 188/98 and decides to retake the blood pressure in an hour. c) The nurse fails to document refusal by the client to ambulate following surgery. d) The nurse documents that the client accurately prepared the correct amount of insulin after instruction was given. e) The nurse administers the client's preoperative medication after the informed consent is signed

B,C

A client newly diagnosed with type 1 diabetes says she is not ready to learn everything about diabetes control right now. Which information has the greatest priority for the nurse to teach this client and her family for now to prevent harm? (Select all that apply.) A) Causes of type 1 diabetes B) What to do when ill? C) Symptoms and treatment of hypoglycemia D) Insulin administration E) Dietary control of blood glucose F) Importance of regular exercise

B,C,D

Which findings does the nurse expect when assessing a client with infect endocarditis? Select all that apply. A. Grating pain that is aggravated by breathing B. Osler nodes on palms of hands and soles of feet C. Slinter hemorrhages D. Janeway lesions on the hands and feet E. Anorexia and weight loss F. Pericardial friction rub

B,C,D,E

Which clients are at greatest risk for development of infective endocarditis? Select all that apply. A. Clients after myocardial infarction B. Clients who are IV drug users C. Clients with poor dental health D. Clients with opioid addictions E. Clients with systemic alterations in immunity F. Clients postoperative after valve replacement

B,C,D,E,F

A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (SATA) a. Teach the client about energy conservation techniques b. Ensure that the client is prescribed a beta blocker c. Document a discussion about advanced directives d. Confirm that a post-discharge nurse visit had been scheduled e. Consult a social worker for additional resources f. Care transition record transmitted to next level of care within 7 days of discharge

B,C,D,F

A nurse answers of patients call light and finds a patient on the floor by the bathroom door after calling for assistance and examining the patient for injury, the nurse helps the patient back to the bed then fills out an incident report. Which statements accurately describes steps of this procedure and why it is performed? Select all that apply. A. An incident report is used as a disciplinary action against staff members B. An incident report is used as a means of identifying risks C. An incident report is used for quality control D. The facility manager completes the incident report E. An incident report makes facts available in case litigations occurs F. Filling of an incident report should be documented in the patient record

B,C,E

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.) a. Weight gain b. Night sweats c. Cardiac murmur d. Abdominal bloating e. Osler's nodes

B,C,E

What assessment findings would the nurse expect to find in a client with right heart failure? Select all that apply. A. Weight loss B. Dependent edema C. Neck vein distention D. Angina E. Hepatomegaly F. Weak peripheral pulses

B,C,E

A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply: A) peripheral edema B) crackles in both lungs C) tachycardia D) ascites E) tachypnea F) S3 gallop

B,C,E,F

Which lifestyle changes will the nurse suggest to a 35-year-old client who has prediabetes to reduce the risk for developing type 2 diabetes? SATA A. Increasing fluid intake B. Increasing physical activity C. Quitting smoking and vaping D. Eliminating all dietary carbohydrates E. Reducing consumption of empty calories F. Keeping body weight at or slightly below ideal

B,E,F

A nurse who is working in a hospital setting uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. A. A patient decides to quit smoking following a diagnosis of lung cancer. B. A patient shows off a new outfit that she is wearing after losing 20 pounds. C. A patient chooses to work fewer hours following a stress-related myocardial infarction. D. A patient incorporates a new low-cholesterol diet into his daily routine. E. A patient joins a gym and schedules classes throughout the year. F. A patient proudly displays his certificate for completing a marathon.

B,F

For which client will the nurse question the diabetes health care provider's prescription fro rosiglitazone? A. 22-year-old with new-onset asthma B. 40-year-old with hyperthyroidism C. 60-year-old with heart failure D. 65-year-old with kidney disease

C

A client admitted to a mental health unit has exhibited physical behaviors that put the client and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which action? A. Slander B. Negligence C. Battery D. Malpractice

C

A client is asking for the nurse to explain acupuncture. What would the nurse tell the client? A) Acupuncture is beneficial to creating a mood of distraction. B) Acupuncture is only done in Eastern countries. C) Acupuncture is used to correct disharmony. D) Acupuncture is a dangerous option for the treatment of disease.

C

A client is scheduled for a colonoscopy. The nurse realizes immediately after administering medications to induce conscious sedation that the client has not signed the informed consent. If the nurse has the client sign the informed consent, which element of informed consent would be violated A)Voluntariness B)Comprehension C) Competence D) Disclosure

C

A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation? A. The nurse should have the client restrained and call the physician. B. The nurse should let the client go because the nurse cannot do anything. C. The nurse should call and inform the nursing supervisor of the situation. D. The nurse should warn the client that the client cannot come to the hospital again.

C

A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse replies, "He is rude. His clients always end up with infections." The nurse is at risk of being accused of which of the following? a) Libel b) Assault c) Slander/defamation d) Negligence

C

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse "I feel no connection to God" and "I'm worried that I find no real meaning in life." What would be the nurse's best response to this patient? a. give the patient a hug and tell him that his life still has meaning b. arrange for a spiritual adviser to visit the patient c. ask if the patient would like to talk about his feelings d. call in a close friend or relative to talk to the patient

C

A lawyer quotes a precedent for punishment of a crime committed by the defendant in a trial. What is court-made law known as? A) Public law B) Statutory law C) Common law D) Administrative law

C

A man who is a declared agnostic is extremely depressed after losing his home, his wife, and his children in a fire. His nursing diagnosis is Spiritual Distress: Spiritual Pain related to inability to find meaning and purpose in his current condition. What is the most important nursing intervention to plan? a. ask the patient which spiritual adviser he would like you to call b. recommend that the patient read spiritual biographies or religious books c. explore with the patient what, in addition to his family, has given his life meaning and purpose in the past d. introduce the belief that God is a loving and personal God

C

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions.

C

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. I have been drinking more water than usual b. I am awakened by the need to urinate at night c. I must stop halfway up the stairs to catch my breath d. I have experienced blurred vision on several occasions

C

A nurse can best help a client who is undergoing chemotherapy and using guided imagery with this by doing which of the following? A) Promoting the client's use of imagery only after a stressful event occurs. B) Explaining to the client that it is not a good idea to record their own imagery tape. C) Assisting the client to find an appropriate imagery tape to use. D) Helping the client learn about the different poses that can be performed.

C

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure activity. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report? A) To evaluate the immediate care provided by the nurse to the client B) To provide a method for deciding the nurse's fault in the incident C) To evaluate quality care and potential risks for injury to the client D) To provides information to local, state, and federal agencies

C

A nurse fails to administer a medication that prevents seizures, and the client has a seizure. The nurse is in violation of the Nurse Practice Act. What type of law is the nurse in violation of? A) Criminal B) Federal C) Civil D) Supreme

C

A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. what is the term for those bringing the charges against the nurse? A. appellate B. defendants C. plaintiffs D. attorneys

C

A nurse is caring for a client with vertigo. During data collection, the nurse finds multiple bruises on the client's arms and back; and suspects the client is being abused.When questioned, the client denies any abuse by the daughter she lives with. Despite the client's denial, which rationale would the nurse use for reporting the suspected abuse? a) The client is ashamed to admit that her daughter is beating her. b) The client does not want anyone to know what is happening in her home. c) The nurse has a legal and ethical responsibility to report the suspected abuse. d) The nurse wants her peers to see her as a hero.

C

A nurse is guiding a patient in the practice of meditation. Which teaching point is most useful in helping the patient to achieve a state of calmness, physical relaxation, and psychological balance? A) Teach the patient to always lie down in a comfortable position during meditation. B) Teach the patient to focus on multiple problems that the patient feels demand attention. C) Teach the patient to let distractions come and go naturally without judging them. D) Teach the patient to suppress distracting or wandering thoughts to maintain focus.

C

A nurse is performing spirituality assessments of patients living in a long-term care facility. What is the best question to assess for spiritual needs? a. can you describe your usual spiritual practices and how you maintain them daily? b. are your spiritual beliefs causing you any concern? c. how can I and the other nurses help you maintain your spiritual practices? d. how you your religious beliefs help you to feel at peace?

C

A nurse is teaching a client experiencing stress about how relaxation helps to reduce the effects of stress on the body. Which underlying concept would the nurse integrate into the explanation about how relaxation works? A) Activates natural pleasure centers B) Slows circulation throughout the body C) Helps to increase the effects of parasympathetic nervous system on the mind and body D) Increases the body's natural immunity

C

A nurse is teaching clients about the use of insulin to treat type 1 diabetes mellitus. For which of the following types of insulin should the nurse tell the clients to expect a peak effect 1 to 5 hr after administration? a. Insulin glargine b. NPH Insulin c. Regular Insulin d. Insulin lispro

C

A nurse is arrested for possession of illegal drugs. What kind of law is involved with this type of activity? A) Civil B) Private C) Public D) Criminal

D

A nurse performing a spiritual assessment collects assessment data from a patient who is homebound and unable to participate in religious activities. Which NANDA-I-approved diagnostic label would the nurse use when assessment data point to a spiritual problem that can be treated by independent nursing intervention? a. spiritual alienation b. spiritual despair c. spiritual distress d. spiritual pain

C

A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a pt's vital signs during a routine eye surgery, leading to the death of the pt. the nurse's attorney explained in the court that the nurse was granted recognition in a specialty area of nursing. what is the term for this type of credential ? A. accreditation B. licensure C. certification D. board approval

C

A nurse threatens to restrain a verbally abusive client if the abuse continues. Which legal tort has the nurse committed? A. Invasion of privacy B. Negligence C. Assault D. Defamation of character

C

A nurse uses Therapeutic Touch to decrease a postoperative client's nausea. Which of the following is a principle of this CAT modality? A) A human being is a closed energy system. B) A human being is bilaterally asymmetric. C) Illness is an imbalance in a person's energy field. D) Humans do not have the ability to transform.

C

A nurse who is caring for patients on a pediatric ward is assessing the children for their spiritual needs. Which is the most important source of learning for a child's own spirituality? a. the child's church or religious organization b. what parents say about God and religion c. how parents behave in relationship to one another and their children, to others, and to God d. the spiritual adviser for the family

C

A nurse who obtains a license to practice nursing by misrepresenting herself is guilty of what tort? a) Slander b) Libel c) Fraud d) Assault

C

A nurse who was raised as a strict Roman Catholic stated she couldn't assist patients with their spiritual distress because she recognizes only a "field power" in each person. She said, "My parents and I hardly talk because I've deserted my faith. Sometimes I feel real isolated from them and also God—if there is a God." Analysis of these data reveals which unmet spiritual need? a. need for meaning and purpose b. need for forgiveness c. need for love and relatedness d. need for strength for everyday living

C

A nurse working in an emergency department assesses how patients' religious beliefs affect their treatment plan. With which patient would the nurse be most likely to encounter resistance to emergency lifesaving surgery? a. a patient of the adventist faith b. a patient who practices buddhism c. a patient who is a jehovah's witness d. a patient who is an orthodox jew

C

A post anesthesia nurse is reporting about a client to the intensive care unit nurse in the elevator. There are staff members and visitors in the elevator. The post anesthesia nurse is doing what? a) maintaining the continuity of care b) implementing therapeutic communication c) breaching the client's confidentiality d) interacting to maintain coordination of care

C

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes d. While your heart is recovering, blood flow is diverted away from the brain, increasing the risk of stroke when you stand up

C

Allen is an 82-year-old retiree who recently relocated to senior apartments. The apartments are not affiliated with any religious beliefs. Allen was raised in the Roman Catholic church and has attended mass every Sunday since childhood. He has not attended mass for 3 weeks. What best describes Allen's situation? A) Change in beliefs B) Spiritual crisis C) Separation from spiritual ties D) Depression

C

An oncology nurse is caring for a client suffering from metabolic encephalopathy and end stage kidney disease. The client has no known family and no advanced directives. Upon entering the room, the nurse observes the client is pale and has no spontaneous respiration. What is the priority action the nurse should take? A) Contact the physician. B) Call the coroner. C) Begin CPR. D) Notify the charge nurse.

C

Based on the etiology and main cause of heart failure, the nurse knows that which client has the greatest need for health promotion measures to prevent heart failure? A. Client with asthma B. Client with renal insufficiency C. Client with hypertension D. Client with Parkinson disease

C

For which finding in a client with mitral valve stenosis would the nurse immediately notify the primary health care provider because of the potential for decompensation? A. Slow, bounding peripheral pulses associated with bradycardia B. An increase and decrease in pulse rate that follows inspiration and expiration C. An irregular heart rhythm and ECG strip that indicate atrial fibrillation D. An increase in pulse rate and blood pressure after exertion

C

How many grams of carbohydrate (CHO) will the nurse provide to a client who has symptoms of hypoglycemia with a blood glucose level between 69 mg/dL and 50 mg/dL to correct he problem and PREVENT HARM? A. 5g B. 10 g C. 15 g D. 30 g

C

Mr. Brown's teenage daughter had been involved in shoplifting. He expresses much anger toward her and states he can not face her, let alone discuss this with her: "I just will not tolerate a thief." Which nursing intervention would the nurse take to assist Mr. Brown with his deficit in forgiveness? a. assure him that many parents feel the same way b. reassure him that many teenagers go through this kind of rebellion and that it will pass c. assist the patient to identify how unforgiving feelings toward others hurt the one who cannot forgive d. ask him if he is sure he has spent sufficient time with his daughter

C

The client is postoperative. The nurse is practicing healing touch with the client. Which of the following would the nurse evaluate as an expected outcome of healing touch? A) The wound is not approximated three days following surgery. B) The client reports pain as a "6" on a 0 to 10 pain scale. C) The client states that his anxiety following surgery has decreased. D) The client's temperature has remained at or below 100.4ºF

C

The health care provider prescribes orders for a client with newly diagnosed uncontrolled seizure activity. When reviewing the prescriptions, the nurse correctly identifies which prescription, if followed, puts him at risk for negligence charges? A) Diazepam (Valium) 5 mg intravenously now B) Oxygen 2/L via nasal cannula C) Restrain all four extremities D) Neurologic assessments every 5 minutes

C

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A) A 50 year old taking repaglinide who has nausea and back pain. B) A 55 year old taking pioglitazone who has bilateral ankle swelling. C) A 45 year old taking metformin who has abdominal cramps. D) A 40 year old taking glyburide who is dizzy and sweaty.

C

The nurse is caring for a client whose treatment has been based on the Ayurveda medical system. Which nursing intervention incorporates this client's beliefs into the nursing plan? A) Basing practice on the yin-yang theory B) Including the client's shaman in the plan of care C) Helping the client to balance his or her dosha D) Preparing the client for exercises that help him or her regulate qi

C

The nurse is caring for a client with heart failure who is on oxygen at 2L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4L. C. Place the client in a high Fowler's position. D. Draw arterial blood for arterial blood gas analysis.

C

The nurse is differentiating beliefs of atheists from agnostics. Which statement is accurate? A) Both deny the existence of God. B) Nurses offer religious counseling to change the beliefs of both groups. C) Both are guided by a philosophy of living that does not include a religious faith. D) Both have religious influences that are life denying.

C

There are four primary scientific principles for therapeutic touch. Which of the following is not one of these principles? A) A human being is bilaterally symmetrical. B) A human being is an open energy system. C) Distractions of modern life interfere with healing agents. D) Illness is an imbalance in an individual's energy field.

C

To improve gas exchange, how much supplemental oxygen would the nurse provide a client with HF? A. 2 L/min by nasal cannula B. 100% by nonrebreather mask C. Within the range prescribed by the HCP to keep saturation at 90% or more D. 50% by endotracheal tube and mechanical ventilator

C

What does the nurse instruct a client with pericarditis to do to make him or her will feel more comfortable? A. Lie down and bend the legs at the knees. B. Sit in a semi-Fowler position with pillows under each arm. C. Sit up and lean forward. D. Lie on the side in a fetal position.

C

What is the best method for the nurse to use when auscultating a client's pericardial friction rub with a stethoscope? A. Place the bell just below the left clavicle. B. Place the diaphragm at the apex of the heart. C. Place the diaphragm at the left lower sternal border. D. Place the bell at several points while the client holds his or her breath.

C

What is the most reliable method of monitoring for fluid gain or loss in a client with heart failure? A. Check for pitting edema in dependent body parts. B. Auscultate the lungs for worsening crackles or wheezes. C. Weigh the client daily at the same time and using the same scale. D. Assess the client's skin turgor and condition of mucous membranes.

C

What is the nurse's BEST response when a client who has type I diabetes asks why he shouldn't try to keep his blood glucose level as close to zero (0) as possible? A. "That would only frustrate you because there are many ways your body prevents your blood glucose level from going below 50 mg/L." B. "You would have to eat absolutely no carbohydrates to accomplish this and just about all food contains some carbohydrates." C. "Glucose is an important nutrient, especially for your brain, and you cannot live if your blood glucose level gets too low." D. "Maintaining such a low glucose level would require a lot of very expensive drugs and not reduce the complications."

C

What is the nurse's best response to a client newly diagnosed with type 1 diabetes who asks why insulin is only given by injection and not as an oral drug? A) "Injected insulin works faster than oral drugs to lower blood glucose levels." B) "Oral insulin is so weak that it would require very high dosages to be effective." C) "Insulin is a small protein that is destroyed in by stomach acids and intestinal enzymes." D) "Insulin is a "high alert drug" and could more easily be abused if it were available as an oral agent."

C

What is the nurse's best response to a client with type 2 diabetes controlled with metformin who asks why now that he is recovering from surgery, is he prescribed to receive insulin therapy for a few days? A) "Your insurance doesn't permit metformin to be used during hospitalization." B) "Your presurgical testing indicates that you now have type 1 diabetes and require daily insulin." C) "You just need insulin temporarily because the stress of surgery causes increased blood glucose levels for a day or two." D) "You must take insulin from now on because the surgery has aggravated the intensity of your diabetes."

C

What type of law regulates the practice of nursing? A) Common law B) Public law C) Civil law D) Criminal law

C

When (at which time) will the nurse plan to monitor for hypoglycemia in a client with type 1 diabetes received regular insulin at 7:00 a.m.? A) 7:30 a.m. B) 7:30 p.m. C) 11:00 a.m. D) 2:00 p.m.

C

When a client admits that he or she sometimes has trouble catching his or her breath, which question would the nurse ask to obtain more information about the client's symptoms? A. "Do you have a history of any medical problems like high blood pressure?" B. "What did you health care provider tell you about your diagnosis?" C. "What was your most strenuous activity during the past week?" D. "How do you feel about being told that you have heart failure?"

C

When a client develops heart failure, what initial compensatory mechanism of the heart does the nurse expect to occur that will maintain cardiac output (CO)? A. Parasympathetic stimulation B. Ventricular hypertrophy C. Sympathetic stimulation D. Renin-angiotensin activation system

C

When obtaining information for a database, which of the following represents a nurse commitment and interest in reflected integrative medicine (CAM)? A) "Which types of foods do you consume in 24 hours?" B) "Which diseases do you suffer from and what are your allergies?" C) "Do you take any vitamins or minerals, and if so, what?" D) "Which prescription medications do you take daily?"

C

Which action is appropriate for the nurse to delegate to the assistive personnel (AP) when caring for clients with diabetes? A) Monitoring a client who reports palpitations and anxiety B) Verifying the infusion rate on a continuous infusion insulin pump C) Performing a blood glucose check on a client who requires insulin D) Assessing a client who reports tremors and irritability

C

Which action will the nurse recommend to a client with type 1 diabetes on insulin therapy who has been having a morning fasting blood glucose (FBG) level of 160 mg/dL (8.9 mmol/L) and is diagnosed with "dawn phenomenon" to achieve better control? A) Eat a bedtime snack containing equal amounts of protein and carbohydrates." B) Avoid eating any carbohydrate with your evening meal." C) Take your evening insulin dose right before going to bed instead of at supper time." D) Inject the insulin into your arm rather than into the abdomen around the navel."

C

Which assessment is a priority for the nurse to make when a client with diabetic ketoacidosis (DKA) who is being monitored while receiving an insulin infusion begins to show an irregular heart beat with inverted T-waves? A) Rate of IV infusion B) Urine output C) Potassium level D) Breath sounds

C

Which best exemplifies malpractice? A. The nurse applies an ice pack to a client's lower back without an order and the client feels better. B. The nurse, using proper body mechanics, assists a client into a locked bed. The client slips and breaks a femur. C. The nurse administers amoxicillin to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest. D. The nurse administers the wrong medication to a client, who then has one episode of vomiting 5 minutes later but no further adverse reactions.

C

Which client assessment finding indicates to the nurse the possible presence of diabetic autonomic neuropathy? A) Loss of sensation in both feet B) Hyperglycemia C) Intermittent constipation D) Increased thirst

C

Which essential medications would the nurse provide teaching about postoperatively for a client who received a prosthetic valve replacement? A. Immunosuppressants B. Antibiotics C. Anticoagulants D. Diuretics

C

Which nursing student would most likely be held liable for negligence? A. A nursing student performs a dressing change using sterile technique and documents the presence of necrotic tissue in the wound. B. A nursing student reports that insulin was not administered to the client by the nurse on the previous shift. C. A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home. D. A nursing student completes an incident report after administering a medication to a client who then experienced an adverse reaction to the medication.

C

Which of the following accreditations is a legal requirement for a school of nursing to exist? A) National League for Nursing Accrediting Commission B) American Association of Colleges of Nursing accreditation C) State Board of Nursing accreditation D) Educational institution accreditation

C

Which of the following is considered a holistic approach to food choices? A) The carbonation in soft drinks is beneficial to health. B) Vegetarian diets should be avoided because they limit options. C) Avoid eating foods with preservatives. D) Increase intake of natural sugar.

C

Which of the following is the most frequent reason for revocation or suspension of a nurse's license? A) Fraud B) Mental impairment C) Alcohol or drug abuse D) Criminal acts

C

Which of the following is the nurse's best legal safeguard? A) Collective bargaining B) Written or implied contracts C) Competent practice D) Patient education

C

Which of the following modes of value transmission is most likely to lead to confusion and conflict? A) Modeling B) Moralizing C) Laissez-faire D) Responsible choice

C

Which of these assessment findings indicate a positive outcome for a client after acupuncture? A) The client has lost 8 lb (3.63 kg) over the last 2 months. B) The client has increased his or her flexibility and strength. C) The client reports a reduction in pain level to 3 out of 10. D) The client has improved balance and coordination.

C

Which precaution is a priority for the nurse to teach a client prescribed pramlintide to prevent harm? A. Only take this drug once weekly B. Do not drink alcohol when taking this drug C. Do not mix in the same syringe with insulin D. Report any genital itching to your primary health care provider

C

Which process evaluates and recognizes educational programs as having met certain standards? A) Certification B) Licensure C) Accreditation D) Credentialing

C

Which serum electrolyte is MOST IMPORTANT for the nurse to monitor closely to PREVENT HARM in a client who has hyperglycemia? A. Sodium B. Chloride C. Potassium D. Magnesium

C

While assessing a client, the client tells the nurse that he is a follower of traditional Chinese medicine and the concept of qi. Based on the nurse's understanding of this concept, which treatment modality would the nurse expect the client to mention? A) Physiotherapy B) Allopathy C) Acupuncture D) Therapeutic Touch (TT)

C

While caring for an infant, the nurse hears another child screaming in the next room. She rushes to the other room to check on the screaming child, forgetting to put the side rails up on the infant's crib. She returns to the room to find the infant has fallen out of the crib and sustained a head injury. Based on the nurse's action, which tort is the nurse liable for? A)Battery B)Assault C)Malpractice D)Defamation

C

The nurse educator is presenting an in-service on nursing and malpractice. Which statements, made by the nursing staff, would indicate to the educator that further teaching is required? Select all that apply. A) "When I document, I make sure it is factual, accurate, complete, and timely." B) "I am accountable for any task that I delegate." C) "If I make a mistake, I will not tell anyone" D) "I will have the supervisor fill out the incident report when I make an error." E) "The nursing plan of care must be accurate and be followed. It is part of the client's permanent record."

C,D

A nurse attempts to integrate complementary and alternative therapies (CAT) into nursing practice. Which of the following are basic principles of CAT? Select all that apply. A) Illness occurs in either the mind or the body, which are separate entities. B) Health is the absence of disease. C) Health is a state characterized by a dynamic balance of mind, body, and spirit. D) Illness is a manifestation of imbalance or disharmony and is a process. E) Curing is accomplished by external agents. F) Healing is a natural, slow process that involves the body, mind, and spirit.

C,D,F

The nurse educator provides an educational session to the nursing staff on protection of a client's privacy. Which circumstances, identified by the staff, would indicate to the educator that the teaching was effective? Select all that apply. A) Because the facility is a teaching facility, the nurse allowed the nursing student to take the client's picture for his care plan. B) The nurse questioned the client about her social life even though it did not affect care planning. C) With the client's permission, the nurse explained the client's diagnosis to the client's spouse. D) During a bed bath, the nurse exposed the client's upper torso while washing the client's face. E)The nurse removed the client from the emergency department waiting room into a private area to collect assessment data.

C,E

A baccalaureate-prepared nurse is applying for a nurse practitioner position. The nurse is: A) Well educated and can perform these duties B) Able to practice as a nurse practitioner C) Educated to practice only with pediatric patients D) Practicing beyond his scope according to licensure

D

A client gets out of bed following hip surgery, falls, and re-injures her hip. The nurse caring for her knows that it is her duty to make sure an incident report is filed. Which of the following statements accurately describes the correct procedure for filing an incident report? A) The physician in charge should fill out the report. B) The names of the staff involved should not be included. C) The reports are used for disciplinary action against the staff. D) The report should contain all the variables related to the incident.

D

A client is received in a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which of the following legal terms describes the case? A)Felony B) Misdemeanor C)Fraud D) Tort

D

A client is taking ginkgo to improve her memory. In the education plan regarding this herb, the nurse should include which of the following? A) It may raise blood pressure. B) Avoid this herb if allergic to plants. C) There is a possible sensitivity to light. D) Use caution if taking aspirin.

D

A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching? A) "I need to brush my teeth at least twice a day and rinse with water." B) "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C) "I need to take a full course of antibiotics prior to my colonoscopy." D) "I will take my blood pressure every day and call if it is too high or low."

D

A family brings the client to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure? A. The nurse informs the family about advance directives. B. The nurse informs the family about the living will. C. The nurse confirms that the client has signed the consent form. D. The nurse confirms that the client's family has signed the consent form.

D

A home care nurse delivers care that incorporates a philosophy that focuses on connections and interactions between parts of the whole. Which term best describes this philosophy? A) Complementary therapy B) Integrative care C) Homeopathy D) Holism

D

A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. which statement is true regarding liability for the administration of the wrong medication? A. The nurse is not responsible, because the nurse was following the doctors orders. B. only the nurses responsible comma because actually administer the medication C. Only the health care provider is responsible, because the health care provider actually provided the drug. D. Both the nurse and the health care provider are responsible for their respective actions.

D

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy b. Hold the next dose c. Instruct the client to drink water d. Administer PRN acetaminophen

D

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. Would you like to speak with a priest or chaplain? b. I will arrange for a psychiatrist to speak with you c. Do you want to come off the transplant list? d. Would you like more information about advance directives?

D

A nurse does not assist with ambulation for a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse? A) Assault B) Battery C) Fraud D) Negligence

D

A nurse exits the room of a confused client without raising the side rails on the bed. The failure to raise the side rails would constitute which element of liability related to malpractice? a) Damages b) Duty c) Causation d) Breach of duty

D

A nurse has been named as a defendant in a lawsuit. With whom should the nurse discuss the case? A) Colleagues B) Reporters C) Plaintiff D) Attorney

D

A nurse is caring for a client who has been taking acarbose for Type 2 Diabetes Mellitus. Which of the following labs should the nurse plan to monitor? a. WBC b. Amylase c. Platelet count d. Liver function tests

D

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement? a. Apply an ice pack to the client's chest b. Provide a neck rub, especially on the left side c. Allow the client to lie in bed with the lights down d. Sit the client up with a pillow to lean forward on

D

A nurse is caring for a postoperative patient who is experiencing pain. Which CHA might the nurse use to ensure active participation by the patient to achieve effective pre- or postoperative pain control? A) Acupuncture B) TT C) Botanical supplements D) Guided imagery

D

A nurse is providing care to a client who has come to the outclient clinic for chemotherapy. The client tells the nurse that to cope with the stress of chemotherapy, he uses a technique in which he "goes to my happy place, the beach, and I picture myself lying there under the warm sun, with the sound of the waves lapping at the shore." The nurse interprets this as which technique? A) Yoga B) Tai chi C) Meditation D) Guided imagery

D

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? a. Avoid drinking more than 3 quarts (3 L) of liquids each day b. Eat six small meals daily instead of three larger meals c. When you feel short of breath, take an additional diuretic d. Weigh yourself each day while wearing the same amount of clothing

D

A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. Avoid taking aspirin or aspirin-containing products b. Increase your intake of foods that are high in potassium c. Hold this medication if your pulse rate is below 80 beats/mind. d. Do not take this medication within 1 hour of taking an antacid

D

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? A) Libel B) Negligence C) Malpractice D) Slander

D

A patient states she feels so isolated from her family and church, and even God "in this huge medical center so far from home." A nurse is preparing nursing goals for this patient. Which is the best goal for the patient to relieve her spiritual distress? a. the patient will express satisfaction with the compatibility of her spiritual beliefs and everyday living b. the patient will identify spiritual beliefs that meet her need for meaning and purpose c. the patient will express peaceful acceptance of limitations and failings d. the patient will identify spiritual supports available to her in this medical center

D

On the advice of friends, a client on a palliative care unit has requested acupuncture. What it is the goal of this form of CAM? A) allowing accumulated toxins to be released from the body B) altering the client's perception and acceptance of reality C) reconnecting the client's body, spirit, and emotions D) restoring a healthy flow of energy along the meridians of the body

D

A patient whose last name is Goldstein was served a kosher meal ordered from a restaurant on a paper plate because the hospital made no provision for kosher food or dishes. Mr. Goldstein became angry and accused the nurse of insulting him: "I want to eat what everyone else does—and give me decent dishes." Analysis of these data reveals what finding? a. the nurse should have ordered kosher dishes also b. the staff must have behaved condescendingly or critically c. Mr. Goldstein is a problem patient and difficult to satisfy d. Mr. Goldstein was stereotyped and not consulted about his dietary preferences

D

A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. this is an example of what type of law? A. public law B. private law C. civil law D. criminal law

D

A veteran nurse, pleaded guilty to a misdemeanor negligent discharge in the case of a 75 year old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. this surgeon who performed the procedure called the nurses action pure negligence, stating that the patient could have been saved. the patient was a vibrant grandmother of 10 who had walked 3/4 of a mile the morning of her surgery and had sung in her church choir the day before. what criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? A. The surgeon who performed the procedure called the nurses actions pure negligence, saying that the patient could have been saved. B. The fact that patient should not have died since she was healthy & physically active. C. the nurse intended to harm the patient and was willfully negligent, as evidenced based by the tragic outcome of routine hernia surgery. D. The nurse had a duty to monitor the pt's vital signs, and due to the nurse's failure to perform, the pt died

D

According to survey results, who are the most prevalent users of complementary or alternative therapies? A) Men, ages 50-65, with some high school, who smoke B) Men, ages 30-45, with college degree, who recently stopped smoking C) Women, ages 25-40, with high school degree, who smoke D) Women, ages 35-50, with college degree, former smokers

D

An on-duty nurse discovers that her colleague is pilfering medicines. According to the Nurse Practice Acts, what shouldthe nurse do? A) Keep silent and overlook the incident B) Inform the local police station C) Discuss this incident with the colleague D) Report the incident to the supervisor

D

Ayurvedic medicine has its roots in which of the following areas? A) China B) Japan C) Southeast Asia D) India

D

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies? A) State legislation B) Board of nursing C) Federal legislation D) Health care institution

D

Even though the nurse performs a detailed nursing history in which spirituality is assessed on admission, problems with spiritual distress may not surface until days after admission. What is the probable explanation? a. patients usually want to conceal information about their spiritual needs b. patients aren to concerned about spiritual needs until after their spiritual adviser visits c. family members and close friends often initiate spiritual concerns d. illness increases spiritual concerns, which may be difficult for patients to express in words

D

How will the nurse response to the client newly diagnosed with type 2 diabetes who asks, "What does having metabolic syndrome and diabetes mean for me?" A. "Metabolic syndrome is helpful to anyone with diabetes because it increases the sensitivity of your cells to the presence of insulin." B. "People with diabetes and metabolic syndrome usually need to us insulin rather than oral anti-diabetic drug to manage their blood glucose levels." C. "Metabolic syndrome is a problem in eliminating drugs from your body, so you will need to be on lower doses of your anti-diabetic drugs to prevent severe side effects." D. "Your risk for having cardiovascular disease is higher and will require good control of your diabetes, blood pressure, and cholesterol to prevent them."

D

In collaboration with the registered dietitian nutritionist, what principle is MOST IMPORTANT for the nurse to reinforce to the client about changes in meal planning needed for management of type I diabetes? A. Eating at least five smaller meal per day plus a bedtime snack B. Taking extra insulin when planning to eat sweet foods C. Ensuring the inclusion of high protein low-carbohydrate, and low-fiber foods D. Considering the effects and peak action times of the prescribed insulin

D

In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing action would most likely be covered by these laws? A. Any emergency care given when consent is obtained B. A negligent act performed in an emergency situation C. Medical advice given to a neighbor regarding a child's rash D. Emergency care for a choking victim in a restaurant

D

Nurses practicing in a critical care unit must acquire specialized skills and knowledge to provide care to the critically ill client. These nurses can validate this specialty competence through what process? A) Litigation B) Accreditation C) Licensure D) Certification

D

The Roman Catholic family of a baby who was born with hydroencephalitis requests a baptism for their infant. Why is it imperative that the nurse provide for baptism to be performed? a. baptism frequently postpones or prevents death or suffering b. it is legally required that nurses provide this care when the family makes this request c. it is a nursing function to assure the salvation of the baby d. lack of baptism when desired may increase the family's sorrow and suffering

D

The nurse is participating in a discussion about controlled substances. Which statement, made by the nurse, indicates the nurse is aware of laws governing the distribution of controlled substances? A) "An impaired nurse is promptly punished by being terminated and having his or her license suspended." B) "When a nurse abuses controlled substances in the workplace and gets help, she will not be charged with a criminal act." C) "The nurse is only at risk if she diverts medication from the client; using personal drugs decrease your risk." D) "Nurses are responsible for adhering to specific documentation about controlled substances."

D

The nurse reviewing the preadmission testing lab values for a 62 year old client scheduled for a total knee replacement finds an A1C value of 6.2%. How will the nurse interpret this finding? A. The clients A1C is completely normal B. The client has type 1 diabetes C. The client has type 2 diabetes D. The client has prediabetes mellitus

D

The pregnant client with hyperemesis is not obtaining relief from medications. Which alternative therapy can the nurse advocate for the client to use? A) Shamanism B) Qi Gong C) Homeopathy D) Acupuncture

D

What does the nurse suspect when a client describes substernal pain that radiates to the left shoulder, is grating, and worsens with inspiration and coughing? A. Chronic constrictive pericarditis B. Cardiac tamponade C. Hypertrophic cardiomyopathy D. Acute pericarditis

D

What is the PRIORITY action for the nurse and other membranes of the inter-professional health care team when caring for an older client admitted with the hyperglycemic-hyperosmolar state (HHS)? A. Replacing potassium B. Preventing ketoacidosis C. Decreasing blood glucose levels D. Increasing circulating blood volume

D

What is the legal source of rules of conduct for nurses? A) Agency policies and protocols B) Constitution of the United States C) American Nurses Association D) Nurse Practice Acts

D

What is the most appropriate action for the nurse to take when a client who has used insulin for diabetes control for 20 years now has a spongy swelling at the site used most frequently for insulin injection? A. Applying ice to this area B. Documenting the finding as the only action C. Assessing the client for other indication of cellulitis D. Instructing the client to use a different site for insulin injection

D

What is the nurse's FIRST action on finding that the blood glucose level of a client with diabetes who is NPO for surgery in the next hour is 150 mg/dL? A. Administer regular insulin IV B. Administer a dose of glucagon C. Notify the surgeon immediately D. Document the finding as the only action

D

What is the nurse's best response to a client newly diagnosed with diabetes who asks why he is always so thirsty? A) "Without insulin, glucose is excreted rather than used in the cells. The loss of glucose directly triggers thirst, especially for sugared drinks." B) "The extra glucose in the blood increases the blood sodium level, which increases your sense of thirst." C) "Without insulin, glucose combines with blood cholesterol, which damages the kidneys, making you feel thirsty even when no water has been lost." D) "The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level."

D

When a client with heart failure walks 200 feet down the hall and develops a feeling of heaviness in the legs, how does the nurse interpret this finding? A. The client is building endurance. B. The activity is appropriate. C. The client could walk farther. D. The activity is too stressful.

D

When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety? A. Warm the vial in a bowl of warm water until it reaches normal body temperature B. Return the vial to the pharmacy and open a fresh vial of NPH insulin C. Roll the vial between the hands until the insulin is clear D. Check the expiration date and draw up the insulin dose

D

When would the nurse expect the release of B-type natriuretic peptide (BNP) for a client with heart failure? A. When the client has an enlarged liver B. When a client's ejection fraction is lower than normal C. When a client develops ventricular hypertrophy D. When a client has fluid overload

D

Which action has the highest priority for the nurse to take when a client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." and has vital signs of: T 98.4° F (36.9° C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air? A) Administering oxygen B) Connecting a cardiac monitor C) Assessing arterial blood gas (ABG) values D) Assessing blood glucose level

D

Which assessment finding in a client with diabetes mellitus indicates to the nurse that the disease is damaging the kidneys? A) White blood cells (WBCs) in the urine during a random urinalysis B) Ketone bodies in the urine during acidosis C) Glucose in the urine during hyperglycemia D) Protein in the urine during a random urinalysis

D

Which client admitted to a surgical unit will the nurse recognize as having a higher risk for having type 2 diabetes? A. 30-year-old Hispanic female runner B. 36-year-old white female who has rheumatoid arthritis C. 40-year-old black male who is 10 lb underweight D. 48-year-old obese male American Indian

D

Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites? A) A 55-year-old client who has hypoglycemic unawareness B) An 80-year-old client with type 2 diabetes mellitus C) A 45-year-old client with type 1 diabetes mellitus D) A 75-year-old client whose blood glucose levels show little variation

D

Which client with valvular heart disease would benefit from the nonsurgical invasive procedure balloon valvuloplasty? A. Older adult who needs a valve replacement B. Middle-aged adult whose open-heart surgery failed C. Young adult with a genetic valve defect D. Older adult who is not a surgical candidate

D

Which condition will the nurse monitor closely for in a client with type I diabetes who has blood glucose level of 438 mg/dL? A. respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

D

Which factor is most important for the nurse to assess before providing instruction to a client newly diagnosed with diabetes about the disease and its management? A) Current energy level and rest patterns B) Sexual orientation C) Current lifestyle for diet and exercise D) Education and literacy levels

D

Which principle does not encompass the basic goals of integrative medicine? A) Establish a partnership between client and practitioner. B) Focus on promoting health and preventing illness, as well as treating disease. C) Facilitate the body's innate healing abilities. D) Reject allopathic medicine and embrace CAM practices.

D

Which statement by a client with a history of hypertension and heart problems would cause the nurse to suspect development of heart failure? A. "I've had a fever frequently." B. "I noticed a very fine red rash on my chest." C. "I get a pain in my shoulder when I cough." D. "I've had to remove all of my rings for the past month."

D

Which type of cardiomyopathy may present with sudden death as the first symptom? A. Dilated B. Arrhythmogenic right ventricular C. Restrictive D. Hypertrophic

D

A nurse is providing teaching to a patient with a new prescription for pramlintide for T1DM. Which of the following should the nurse include in the teaching?(Select all that apply) a. "Take oral medications 30 min before injections" b. "Use upper arms as preferred injection sites c. "Mix pramlintide with the breakfast dose of insulin." d. "Inject pramlintide just before a meal." e. "Discard open vials after 28 days."

D, E

A 35-year-old woman diagnosed with diabetes tells her nurse that she would be interested in finding out about complementary therapies that are available. What would be the nurses best response to this patient? A) It is best to stick with allopathic medicine when dealing with diabetes. B) Complementary therapies are not available for this disease state. C) Complementary therapies are not covered by your insurance plan. D) Complementary therapies are being used as an answer to the problem of chronic illness.

D

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? A. "I will sign as a witness to your signature." B. "You will need to find a witness on your own." C. "Whoever is available at the time will sign as a witness for you." D. "I will call the nursing supervisor to seek assistance regarding your request.

D

A middle-aged man is having increasing difficulty breathing. He never exercises, eats fast food regularly, and smokes two packs of cigarettes a day. He tells the nurse practitioner that he wants to change the way he lives. What is one means of helping him change behaviors? A) Ethical change strategy B) Values neutrality choices C) Values transmission D) Values clarification

D

A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? A. Altruism B. Autonomy C. Human dignity D. Integrity

D

A nurse listens to a tape of humorous stories at least once a week for its therapeutic effect. What system is improved by laughter? A) cardiovascular system B) respiratory system C) immune system D) lymphatic system

C

A nurse provides client care within a philosophy of ethical decision making and professional expectations. What is the nurse using as a framework for practice? A) Code of Ethics B) Standards of Care C) Definition of Nursing D) Values Clarification

A

A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse's action reflects which principle of bioethics? A. Autonomy B. Beneficence C. Justice D. Fidelity E. Nonmaleficence

E

A nurse states to the client that she will keep her free of pain. However, her family wishes to try a treatment to prolong her life that may necessitate withholding pain medication. This factor will cause an ethical dilemma for the nurse in relation to which ethical principle? A) Fidelity B) Veracity C) Justice D) Autonomy

A

A nurse who is a traditional Chinese medicine practitioner is providing home care to a patient who also uses traditional Chinese medicine for healthcare. What specific assessments would the nurse make? A) tongue and pulses B) abdominal muscles and respirations C) muscle tone and cranial nerves D) vision and hearing

A

A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected? A) Respecting the client's desire to have the uncle make choices on her behalf B) Revisiting the decision when the uncle is not present at the bedside C) Teaching the client about her right to autonomy D) Holding a family meeting and encouraging the client to speak on her own behalf

A

What philosophy underlies the use of CAT? A) The mind, body, and spirit function as a unified whole. B) The mind and the body are separate and distinct. C) Parts of an organism rarely interact or change. D) Traditional medicine is most effective for chronic illnesses.

A

A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? A)The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention. B)The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible. C)The nurses have given multiple opportunities for potential participants to ask questions, and have been following the informed consent process systematically. D)The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time.

A

A home health nurse who performs a careful safety assessment of the home of a frail elderly patient to prevent harm to the patient is acting in accord with which of the following, a principle of bioethics? A) Nonmaleficence B) Advocacy C) Morals D) Values

A

A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse's commitment to the principle of autonomy? A. The nurse helps the patient prepare a durable power of attorney document. B. The nurse gives the patient undivided attention when listening to concerns. C. The nurse keeps a promise to provide a counselor for the patient. D. The nurse competently administers pain medication to the patient.

A

A male client age 56 years is experiencing withdrawal from alcohol and is placing himself at risk for falls by repeatedly attempting to scale his bed rails. Benzodiazepines have failed to alleviate his agitation and the nurse is considering obtaining an order for physical restraints to ensure his safety. The nurse should recognize that this measure may constitute what? A) Paternalism B) Deception C) Harm D) Advocacy

A

A mother always thanks clerks at the grocery store. Her daughter age 6 years echoes her thank you. The child is demonstrating what mode of value transmission? A) Modeling B) Moralizing C) Reward and punishment D) Responsible choice

A

A nurse has had, on several occasions, the opportunity to share personal prescriptions with family members when they were in need of pain medication or antibiotics. Which set of rules should govern this moral decision? A) Ethics B) Administrative law C) Common law D) Civil law

A

A nurse in a physician's office has noted on several occasions that one of the physicians frequently obtains controlled drug prescription forms for prescription writing. The physician reports that his wife has chronic back pain and requires pain medication. One day the nurse enters the physician's office and sees him take a pill out of a bottle. The doctor mentions that he suffers from migraines and that his wife's pain medication alleviates the pain. What type of nurse physician ethical situation is illustrated in this scenario? A) Unprofessional, incompetent, unethical, or illegal physician practice B) Disagreements about the proposed medical regimen C) Conflicts regarding the scope of the nurse's role D) Claims of loyalty

A

A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability? A. filling out an occurrence report and notifying the health care provider B. documenting in the chart a narrative note about the occurrence C. telling the client that the medication will be given the following morning D. administering the medication with the other evening medications

A

A nurse is caring for a client who is a practicing Jehovah's Witness. The physician orders two units of packed cells based on his low hemoglobin and hematocrit levels. The nurse states to the surgeon that it is unethical to go against the patient's beliefs even though his blood counts are very low. What is the best description of the nurse's intentions? A) Acting in the patient's best interest B) Siding with the patient over the surgeon C) Observing institutional policies D) Being legally responsible

A

A nursing instructor is teaching a class about ethical principles to a group of nursing students. The instructor determines that the teaching was successful when the students give which of the following as an example of nonmaleficence? A) Protecting clients from a chemically impaired practitioner B) Performing dressing changes to promote wound healing C) Providing emotional support to clients who are anxious D) Administering pain medications to a client in pain

A

A patient is taking ginkgo biloba, a botanical supplement. She asks the nurse if it would be safe to take aspirin for her arthritis at the same time. The nurses response is based on what knowledge? A) Ginkgo biloba affects platelet function and should not be taken with aspirin. B) Aspirin will not have any effect if taken at the same time as ginkgo biloba. C) Ginkgo biloba does not have any effect on the blood, so it is safe. D) Ginkgo biloba has an anticoagulant effect and aspirin decreases clotting

A

A patient with rheumatoid arthritis complains of soreness in his joints. Which of the following homeopathic remedies might the nurse recommend for this patient? A) arnica B) calendula C) nux vomica D) ignatia

A

A professional nurse committed to the principle of autonomy would be careful to: A. Provide the information and support a patient needed to make decisions to advance one's own interests. B. Treat each patient fairly, trying to give everyone his or her due C. Keep any promises made to a patient or another professional caregiver D. Avoid causing harm to a patient

A

A student nurse is working in the library on her plan of care for a clinical assignment. The client's name is written at the top of her plan. What ethical responsibility is the student violating? A) Confidentiality B) Accountability C) Trust D) Informed consent

A

An older nurse asks a younger coworker why the new generation of nurses just aren't ethical anymore. Which reply reflects the BEST understanding of moral development? A. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." B. "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" C. "Ethics is genetically determined...it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." D. "I agree! It's impossible to be ethical when working in a practice setting like this!"

A

Nursing is expanding its knowledge base to include information that explains selected CAT. Which of the following describes an aspect of CAT? A) market driven B) nurse driven C) government regulated D) last-resort therapy

A

The children of a female client 78 years of age with a recent diagnosis of early-stage Alzheimer's disease are attempting to convince their mother to move into an assisted living facility, a move to which the client is vehemently opposed. Both the client and her children have expressed to the nurse how they are entrenched in their position. Which of the following statements expresses a utilitarian approach to this dilemma? A) The decision should be made in light of consequences. B) The client's autonomy and independence are the priority considerations. C) Benefits and burdens should be evenly distributed between the children and the client. D) The client has a right to self-determination.

A

The client was diagnosed with diabetes three years ago, but has failed to integrate regular blood glucose monitoring or dietary modifications into his lifestyle. He has been admitted to the hospital for treatment of acute renal failure secondary to diabetic nephropathy, an event that has prompted the client to reassess his values. Which of the following actions most clearly demonstrates that this client is engaging in the step of prizing within his valuing process? A) The client expresses pride that he now has the knowledge and skills to take control of his diabetes management. B) The client states that he will now begin to check his blood glucose before each meal and at bedtime. C) The client is now able to explain how his choices have contributed to his renal failure. D) The client expresses remorse at how his failure to take make lifestyle changes has adversely affected his health.

A

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? A. Contact the nursing supervisor. B. Administer the dose prescribed. C. Hold the medication until the PHCP can be contacted.4 D. Administer the recommended dose until the PHCP can be located.

A

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next? A. Reassess the client. B. Conduct a staff meeting to describe the fall. C. Contact the nursing supervisor to update information regarding the fall. D. Document in the nurse's notes that an occurrence report was completed.

A

Which of the following best describes feminist ethics? A. An approach critiquing existing patterns of oppression and domination in society. B. A combination of elements of utilitarian and deontologic theories that offers specific action guides for practice. C. The formal study of ethical issues that arise in the practice of nursing. D. Attention directed to the specific situation of individual patients viewed within the context of their life narratives.

A

Which of the following nursing actions is an example of using integrative care? A) A nurse instructs a laboring woman to use breathing exercises and assists with the administration of an epidural for her pain. B) A nurse monitors the heartbeat of a fetus and charts the height of the mothers fundus on the medical record. C) A nurse provides music therapy along with relaxation techniques for residents of a long-term facility. D) A nurse performing a home assessment of an elderly patient recommends a referral to social services.

A

Which identifies accurate nursing documentation notation(s)? Select all that apply. A. The client slept through the night. B. Abdominal wound dressing is dry and intact without drainage. C. The client seemed angry when awakened for vital sign measurement.4 D. The client appears to become anxious when it is time for respiratory treatments. E. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

A, B, E

A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply. A. Advocacy is the protection and support of another's rights. B. Patient advocacy is primarily performed by nurses. C. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities. D. Nurse advocates make good health care decisions for patients and residents. E. Nurse advocates do whatever patients and residents want. F. Effective advocacy may entail becoming politically active.

A, C, F

Which of the following populations are more inclined to use CAT? Select all that apply. A) women B) adults aged 20 to 30 C) people living in the east D) former smokers E) adults who are poor F) adults with higher levels of education

A, D, F

Which of the following are examples of a nurse demonstrating the professional value of altruism? Select all that apply. A) The nurse arranges for an interpreter for a client whose primary language is Spanish. B) The nurse calls the physician of a client whose pain medication is not strong enough. C) The nurse provides information for a client so he is capable of participating in planning his care. D) The nurse reviews a client chart to determine who may be informed of the patient's condition. E) The nurse documents client care accurately and honestly and reviews the entry to ensure there are no errors.

A,B

A nurse mentor is teaching a new nurse about the underlying beliefs of CHAs versus allopathic therapies. Which statements by the new nurse indicate that teaching was effective? Select all that apply. A) "CHA proponents believe the mind, body, and spirit are integrated and together influence health and illness." B) "CHA proponents believe that health is a balance of body systems: mental, social, and spiritual, as well as physical." C) "Allopathy proponents believe that the main cause of illness is an imbalance or disharmony in the body systems." D) "Curing according to CHA proponents seeks to destroy the invading organism or repair the affected part." E) "The emphasis is on disease for allopathic proponents and drugs, surgery, and radiation are key tools for curing." F) "According to CHA proponents, health is the absence of disease."

A,B,E

A client who is scheduled to have surgery for a hernia the next day is anxious about the whole procedure. The nurseassures the client that surgery for hernias is very common and that the prognosis is very good. What skills of the nurse are reflected here? A) Imaginal skills B) Interpersonal skills C) Instrumental skills D) Systems skill

B

A dying client tells the nurse that he doesn't want to see his family because he doesn't want to cause them more sadness.Which action by the nurse is most appropriate? A) Arrange a meeting between the family and the client. B) Help the patient clarify his values. C) Educate the patient on death and dying concepts. D) Allow the patient time for quiet reflection.

B

A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute? A. Providing honest information to patients and the public B. Promoting universal access to health care C. Planning care in partnership with patients D. Documenting care accurately and honestly

B

A nurse practitioner uses integrative care in his practice. What does this mean? A) He uses allopathic medicine to treat all patients. B) He uses both allopathic medicine and CAT. C) The nurse uses CAT, a physician-prescribed medication. D) The nurse provides care for patients of all age groups.

B

A nurse shows client advocacy by: A. sending a client home with verbal discharge instructions. B. offering a hospice consultation to a client who is terminally ill. C. insisting that a medication be taken. D. refusing to allow a spouse to stay by the bedside.

B

A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient's doctor threatens the nurse with firing if the nurse raises questions about the patient's care or calls the consult. What ethical conflict is this nurse experiencing? A. Ethical uncertainty B. Ethical distress C. Ethical dilemma D. Ethical residue

B

A nursing faculty is presenting a lecture on ethics. The correct definition of ethical distress is: A. supporting the rights of a client during hospitalization B. knowing the correct action, but unable to perform due to constraints C. being aware of the principles of right and wrong D. belief about worth as a standard to guide behavior

B

A trained nurse uses the technique of Rolfing to break up tension in patient body structures. What type of CAT is being used by this nurse? A) Therapeutic Touch B) therapeutic massage C) acupuncture D) healing touch

B

An ethical conflict exists around a female client's expressed desire to have a neighbor make her treatment decisions. This neighbor is an individual who the client's children characterize as a predator. Place in the correct order the steps that the nurse should follow in resolving this ethical conflict. 1. Clearly identify the ethical problem 2. Apply ethical principles to the situation 3. Identify the different options 4. Gather relevant data about the situation 5. Make and evaluate a decision A) 1, 2, 3, 4, 5 B) 4, 1, 3, 2, 5 C) 2, 3, 4, 1, 5 D) 1, 4, 3, 2, 5

B

At a follow-up visit, a patient recovering from a myocardial infarction tells the nurse: "I feel like my life is out of control ever since I had the heart attack. I would like to sign up for yoga, but I don't think I'm strong enough to hold poses for long." What would be the nurse's best response? A) "Right now you should concentrate on relaxing and taking your blood pressure medicine regularly, instead of worrying about doing yoga." B) "There is a slower-paced yoga called Kripalu that focuses on coming into balance and relaxation that you could look into." C) "Ashtanga yoga is a gentle paced yoga that would help with your breathing and blood pressure." D) "Yoga is contraindicated for patients who have had a heart attack."

B

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? A. Libel B. Slander C. Assault D. Negligence

B

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? A. Refuse to float to the ICU based on lack of unit orientation. B. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. C. Ask the nursing supervisor to review the hospital policy on floating. D. Submit a written protest to nursing administration, and then call

B

What is one belief of Native American healing practices? A) Modern life facilitates potential healing agents. B) Healing takes time, time contributes to healing. C) A balance of yin and yang is important to health. D) Energy flows through meridians throughout the body.

B

What is the function of the American Nurses Association's Code of Ethics for Nurses? A) Serves to establish personal ethics for nurses B) Delineates nurses' conduct and responsibilities C) Serves as a guideline for all health care practice D) Plays an important role in legal proceedings

B

When a nurse refuses to compromise a client's right to privacy, even when the nurse is threatened, the nurse is expressing an ethical framework termed what? A) Utilitarian B) Deontologic C) Justice D) Nonmaleficence

B

Which word is best described by the following: the protection and support of another's rights? A. Ethics B. Advocacy C. Paternalism D. Autonomy

B

While at lunch, a nurse heard other nurses at a nearby table talking about a client they did not like. When they asked him what he thought, he politely refused to join in the conversation. What value was the nurse demonstrating? A) The importance of food in meeting a basic human need B) Basic respect for human dignity C) Men do not gossip with women D) A low value on collegiality and friendship

B

A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe this process? Select all that apply. A. People are born with values. B. Values act as standards to guide behavior. C. Values are ranked on a continuum of importance. D. Values influence beliefs about health and illness. E. Value systems are not related to personal codes of conduct.f. Nurses should not let their values influence patient care.

B, C, D

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. A. Complete and file an occurrence report.2 B. Right-click on the entry and modify it to reflect the correct information. C. Document the correct information and end with the nurse's signature and title. D. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. E. Document in a nurse's note in the client's record detailing the corrected information

B, C, D, E

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? A. Obtain a court order for the surgical procedure. B. Ask the EMS team to sign the informed consent. C. Transport the victim to the operating room for surgery. D. Call the police to identify the client and locate the family.

C

A client is scheduled to have an elective surgical procedure performed and cannot decide if he wants to do it or not. He asks the nurse to help him make the decision because he does not feel that he knows enough about the procedure. Which of the following is the best way for this nurse to advocate for this client? A. Refer the client to the social worker so that she can call in the people who need to help him make his decision. B. Call the surgeon and have him explain the procedure again. C. Facilitate the client's decision by allowing him to verbalize his feelings and by providing information to help him assess his options. D. Refuse to help the client and state that he must make the decision on his own.

C

A client nearing the end of life requests that he be given no food or fluids. The physician orders the insertion of a nasogastric tube to feed the client. What situation does this create for the nurse providing care? A) Nurse must follow the physician's orders B) An inability to provide care for the patient C) An ethical dilemma about inconsistent courses of action D) A barrier to establishing an effective nurse-patient relationship

C

A client, unsure of the need for surgery, asks the nurse, "What should I do?" What answer by the nurse is based on advocacy? A) "If I were you, I sure would not have this surgical procedure." B) "Gosh, I don't know what I would do if I were you." C) "Tell me more about what makes you think you don't want surgery." D) "Let me talk to your doctor and I will get back to you as soon as I can."

C

A home care nurse visits a client who is confined to bed and is cared for by her daughter. The daughter is known to suffer from chemical dependence. The home is cluttered and unclean. During the assessment the nurse notes that the client is wet with urine and has dried feces on her buttocks, and demonstrates signs of dehydration. After caring for the client, the nurse contacts the physician and reports the incident to Adult Protective Services. This is an example of which ethical framework? A) Justice B) Autonomy C) Nonmaleficence D) Fidelity

C

A nurse has a duty of nonmaleficence. Which of the following would be considered a contradiction to that duty? A) Provide comfort measures for a terminally ill patient. B) Assist the patient with ADLs. C) Refuse to administer pain medication as ordered. D) Provide all information related to procedures.

C

A nurse in a women's health clinic values abstinence as the best method of birth control. However, she offers compassionate care to unmarried pregnant adolescents. What is the nurse demonstrating? A) modeling of value transmission B) conflict in values acceptance C) nonjudgmental "value neutral" care D) values conflict that may lead to stress

C

A nurse is applying healing touch to a postoperative patients wound. What benefits of healing touch would the nurse tell the patients family? A) It will decrease the need for fluids after surgery. B) It will help your family relationships. C) It will help the wound heal. D) It will improve the nurse patient relationship.

C

A nurse is caring for a client who is a celebrity in the area. A person claiming he is a family member inquires about the medical details of the client. The nurse reveals the information but later comes to find out that the person was not a family member. The nurse has violated which of the following? A) Veracity B) Fidelity C) Confidentiality D) Autonomy

C

A nurse is caring for a woman 28 years of age who has delivered a baby by Cesarean section. She describes her pain as a 9. The nurse medicates her for pain. This is an example of which of the following ethical frameworks? A) Justice B) Fidelity C) Beneficence D) Nonmaleficence

C

A nurse is providing a lecture on CHAs to a group of patients in a rehabilitation facility. Which teaching point should the nurse include? A) CHAs are safe interventions used to supplement traditional care. B) Many patients use CHA as outpatients but do not wish to continue as inpatients. C) Many nurses are expanding their clinical practice by incorporating CHA to meet the demands of patients. D) Most complementary and alternative therapies are relatively new and their efficacy has not been established.

C

A nurse is researching a standardized herbal supplement to help a patient with pain. What does the word standardized mean? A) It is an all-natural product. B) It is not contaminated by other ingredients. C) It contains a certain amount of an active ingredient. D) It can be toxic in higher than regular doses.

C

A nurse uses Therapeutic Touch to decrease a postoperative patients nausea. Which of the following is a principle of this CAT modality? A) A human being is a closed energy system. B) A human being is bilaterally asymmetric. C) Illness is an imbalance in a persons energy field. D) Humans do not have the ability to transform

C

A nurse working in a long-term care facility has an elderly male client who is very confused. What ethical dilemma is posed when using restraints in a long-term care setting? A) It limits personal safety. B) It increases confusion. C) It threatens autonomy. D) It prevents self-directed care.

C

A nursing student is studying the principle of autonomy. Which example most accurately depicts this principle? A. transporting a client to a scheduled physical therapy appointment B. administering a morning dose of insulin before breakfast C. describing surgery to a client before the consent is signed D. changing a dressing on a wound as needed

C

A woman age 83 years who has suffered a cerebrovascular accident and is unable to swallow refuses the insertion of a feeding tube. This is an example of what ethical principle? A) Nonmaleficence B) Veracity C) Autonomy D) Justice

C

A young mother experiences nausea and diarrhea when stressed. What mindbody messenger is believed to be responsible for these responses? A) reproductive hormones B) white blood cells C) neuropeptides D) pancreatic insulin

C

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? A. Call the police. B. Cut up the photograph and throw it away. C. Call the nursing supervisor and report the occurrence. D. Call the laboratory and ask for the name of the individual who sent the photograph.

C

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? A. The client fell out of bed. B. The client climbed over the side rails. C. The client was found lying on the floor. D. The client became restless and tried to get out of bed.

C

The nurse medicates her for pain. This is an example of which of the following ethical frameworks? A) Justice B) Fidelity C) Beneficence D) Nonmaleficence

C

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? A. Call security. B. Call the police. 179 C. Call the nursing supervisor. D. Lock the coworker in the medication room until help is obtained.

C

A nurse is concerned about the practice of routinely ordering a battery of laboratory tests for clients who are admitted to the hospital from a long-term care facility. An appropriate source in handling this ethical dilemma would be which of the following? A) The client's family B) The admitting physician C) The nurse in charge of the unit D) The institutional ethics committee

D

A nurse is conducting a health history and asks the patient about use of complementary and alternative therapies (CAT) to treat her chronic headaches. What response would require further questions? A) I practice meditation. B) I use relaxation to help me go to sleep. C) Each week, I have a total body massage. D) I take herbs to treat my headaches

D

A nurse is practicing imagery to relieve stress. What might accompany the imagery to even further promote relaxation? A) bright lighting B) bodywork techniques C) talking on the phone D) listening to music

D

A nurse is teaching a patient about the proper use of herbs and supplements. Which of the following statements would be included? A) Look on the Internet for the products you want to try. B) The federal government regulates supplements. C) It doesnt matter how much you take. D) The product may take a longer time to be effective.

D

A nurse is teaching her patients about a holistic approach to food choices. Which of the following would the nurse recommend? A) Consume more dairy products. B) Use artificial sweeteners instead of sugar. C) Drink diet sodas instead of regular sodas. D) Reduce intake of refined and natural sugars.

D

A nurse on the oncology unit is caring for a client on hospice care. The client is weak and is resting. The client's daughter comes storming onto the unit and demands that the nurse do everything she can to treat her mother. This is an example of what type of values conflict? A. Ethical conflict B. Individual conflict C. Health care conflict D. Family conflict

D

A nurse practices holistic patient care. Which of the following is a guiding principle of this practice? A) Holism is focused on reductionism. B) All living organisms exist independently. C) The body is the sum of its parts. D) The body is a unified, dynamic whole.

D

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that 180 represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? A. Performing a procedure without consent B. Threatening to give a client a medication C. Telling the client that he or she cannot leave the hospital D. Observing care provided to the client without the client's permission

D

A patient interested in acupuncture asks a nurse, Just exactly what does it do? What would the nurse explain? A) Acupuncture is based on a philosophy of laying on of hands. B) I don't think it does anything, so I don't know anything about it. C) It uses a manual process of adjusting the spine. D) It changes the flow of energy and helps healing

D

A pediatric nurse is assessing a 5-year-old boy who has dietary modifications related to his diabetes. His parents tell the nurse that they want him to value good nutritional habits, so they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? A. Modeling B. Moralizing C. Laissez-faire D. Rewarding and punishing

D

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? A. "Oh, really? I will discuss this situation with your son." B. "Let's talk about the ways you can manage your time to prevent this from happening." C. "Do you have any friends who can help you out until you resolve these important issues with your son?" D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

D

Two children need a kidney transplant. One is the child of a famous sports figure, whereas the other child comes from a low-income family. What ethically relevant consideration is important to the nurse as an advocate for these clients? A) Balance between benefits and harms in patient care B) Norms of family life C) Considerations of power D) Cost-effectiveness and allocation

D

What is the ultimate goal of increasing the parasympathetic system influence on the body through relaxation or meditation? A) stimulate improved gastrointestinal function B) increase cardiac output and blood pressure C) facilitate respiratory function and cough D) reduce the effects of stress on the body

D

Which of the following essential oils can be used during aromatherapy to treat nausea? A) lavender B) garlic C) parsley D) peppermint

D

Which of the following is a characteristic of the care-based approach to bioethics? A. the need to emphasize the relevance of clinical experience B. the need for an orientation toward service C. The rightness or wrongness of an action is independent of its consequences. D. the promotion of the dignity and respect of clients as people

D