Final Exam for Fundamentals

After a visit with the health care provider, the nurse calculates the client's body mass index (BMI). Which statement by the nurse best informs the client of the purpose of BMI?

"BMI is used to screen for weight categories that can lead to health problems." BMI is a person's weight in kilograms divided by the square of height in meters. A high BMI can be an indicator of high body fatness. BMI can be used to screen for weight categories that may lead to health problems, but it is not diagnostic of the body fatness or health of an individual. Insurance companies have weight charts and do not use BMI for screening. The BMI does not refer to the weight that makes a person feel more comfortable.

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply.

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?" The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

A Penrose drain promotes passive drainage into a dressing. A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately. In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity. Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every 2 hours.

The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching?

Grapefruit Constipation may be avoided, minimized, or eliminated with proper food selection. Citrus fruits, such as grapefruit, are good choices for a client with constipation as they are rich in soluble fiber pectin, which increases gastrointestinal motility. Bacon contains high fat, which increases constipation. Eggs are low in fiber and high in fat, which slows gastrointestinal motility. Fat in whole milk is constipating.

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen?

Impaired Skin Integrity related to open wound Impaired skin integrity best describes the minor laceration. While the other diagnoses, Pain, Knowledge Deficit, and Risk for Infection, are all possible as a result of the laceration, there is no indication in the scenario that they are the case.

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?

Inform the physician about this finding. The first line of defense against infection is intact skin and mucous membranes covering body cavities. They are the most important barriers to infection, and when they are intact, infection is rare. Chemical composition aids these physical barriers further. For example, the acidic nature of the skin and vagina helps to kill potential invaders before they enter the body. Certain illness or treatments can interfere with the body's delicate balance, causing overgrowth of Candida fungus.

When applying an external heating pad, which prescription from the health care provider would the nurse question?

Leave heating pad on for 45 minutes The nurse should question the prescription to leave the heating pad on for 45 minutes, because this is too long and could cause complications such as burns. The maximum time limit should be no more than 30 minutes. Using heat for more than 30 minutes can result in tissue congestion, vasoconstriction, and increases the risk of tissue damage. It is important for the nurse to frequently assess the site during the application to ensure no adverse affects are occurring. The nurse should use either gauze or tape to hold the heating pad in the correct location; however, pins should not be used as they may puncture and damage the pad. The temperature should be maintained between 105°F to 109°F (40.5°C to 43°C) to ensure the best therapeutic results.

A client who was receiving care on a psychiatric unit died by suicide at a time when nurses are known to have been handing off to nurses on the next shift. What is a responsibility of the organization when responding to this sentinel event?

Report the event to the Joint Commission. Hospitals are required to report serious safety and sentinel events to regulatory agencies such as the Joint Commission and to state health agencies. There is no formal responsibility to inform other local institutions. There is no obvious need for discipline, though education may be needed. Policies and procedures would be reviewed, but may not need to be changed.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises. The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.

The nurse is providing client education about the use of herbal medicines. Which statements are accurate? Select all that apply.

They take longer to produce a therapeutic effect. They can be toxic in high doses. They contain certain amounts of active ingredients. Herbal medicines do take longer to produce a therapeutic effect, can be toxic in high doses, and do contain certain amounts of active ingredients. They are not regulated by the government and many cannot be safely taken with other medications.

According to survey results, who are the most prevalent users of complementary or alternative therapies?

Women, ages 35-50, with college degree, former smokers The most prevalent users of CAT are women, ages 35-50, with higher levels of education, who are former smokers.

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?

cleansing enema The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction, promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy), establish regular bowel function, and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus.

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema?

left side-lying When administering a cleansing enema, the client is most often positioned in a left side-lying (Sims') position. Prone is lying flat, especially face downward. Visualization of the rectum is acceptable but insertion of the enema is difficult. The supine position means lying horizontally with the face and torso facing up, and this is not helpful for inserting an enema as a nurse cannot visualize the rectum. The right side-lying position is used for positioning of a client, not for an enema.

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

protein Complete proteins contain sufficient amounts of the essential amino acids to maintain body tissues and to promote growth.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

A nurse is reviewing the teaching plan about heart failure with a client. The nurse determines that learning in the affective domain has been achieved based on which client statement?

"I realize now just how important it is to watch how much salt I use." Affective learning includes changes in attitudes, values, and feelings, as evidenced by the client's statement about realizing the importance of watching salt intake. Statements about signs and symptoms, taking a water pill, and calling the provider reflect learning in the cognitive domain.

When looking at a model for evidence-based practice, what is the final step of the process?

Evaluating practice change The fifth and final step in the process of implementing evidence-based practice is to evaluate and critically appraise the change in practice. Formulating a clinical question and searching and appraising the literature precede this step.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV. The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

Which observation during the nursing assessment of a client supports the documentation of low health literacy?

The client avoids health care screenings and seeks care in the local emergency department. Lack of follow-up on tests and referrals, missing appointments (such as health care screenings), being unable to provide a coherent health history, having incomplete health forms, and exhibiting noncompliance with the medication regimen are indications that the client has low health literacy.

Professional regulations and laws that govern nursing practice are in place for which reason?

To protect the safety of the public Governing bodies, professional regulations, and laws are in place to protect the public by ensuring that nurses are accountable for safe, competent, and ethical nursing practice. The other options do not describe accurately the role and responsibility of the governing bodies and the regulations and laws of nursing.

The nurse is caring for a client who demonstrates a health literacy concern. The nurse adjusts client teaching in which way?

uses videos, diagrams, and pictures rather than focusing on verbal teaching To address health literacy concerns, the nurse should avoid technical language, limit information to three to five key points, and be specific rather than general. Using medical terminology to help the client feel smarter, providing general teaching instead of specific teaching, and giving instructions in multiple ways are not effective ways to adjust client teaching for those who demonstrate low health literacy.

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting." There are many benefits to electronic charting, though there may be some learning curves involved in knowing how to use electronic formats. It is incorrect to suggest that overtime pay can be earned with end-of-shift charting. Therefore, this statement requires intervention. The other statements are appropriate.

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 durable power of attorney for health care appoints an agent the person trusts to make decisions. Advance directives can minimize difficulties by allowing people to state in advance what their choices would be for health care if certain circumstances arise. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. In the United States, the Patient Self-Determination Act of 1990 requires all hospitals to inform patients about advance directives. Advance directives do not have to be completed prior to hospitalization in order to be valid.

Which example best describes feminist ethics?

An approach critiquing existing patterns of oppression and domination in society

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care. A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

A client is admitted to the health center with chronic diarrhea. When should the nurse begin imparting health teaching about the benefits of proper diet to the client so that the risk of diarrhea is minimized?

When admitting the client Potential teaching needs should be identified from the time when the client is admitted. The client would therefore need to be taught the benefits of a proper diet during admission so as to minimize the risk of diarrhea. There is a greater probability of the client retaining the teaching if the teaching starts during admission. The teaching may be amended during the caring, treatment, and discharge phases, as well as during any follow-up treatment.

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?

Working phase During the working phase, the nurse and client explore and develop solutions that are enacted and evaluated in subsequent interactions. The orientation phase involves making introductions and establishing client goals. The termination phase involves evaluating client progress toward goals and concluding the relationship. There is no evaluation phase in the nurse-client

A client shares with the nurse how much the client appreciates understanding the physiology of breastfeeding. The client states, "I felt very comfortable with what you explained to me, and I feel I will be successful at breastfeeding." In affective learning, this represents the nurse:

creating an atmosphere for discussion of feelings. When working with clients to change beliefs, values, and attitudes (i.e., affective learning), the nurse creates an atmosphere in which clients can honestly and freely discuss their feelings and emotions. Creating specific learning sessions for new information and creating an opportunity for rational thought and learning pertain more to cognitive learning, which involves the client's critical thinking and reason. In this scenario, the nurse has provided an educational opportunity in the present, not for the future.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning. Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

sit with the client and ask them about their feelings Somatization is manifesting an emotional stress through a physical disorder. Treating the nausea with an antiemetic will not get at the root cause of the emotional issue. Contacting the primary care provider is not appropriate, as the diagnosis of somatization is present. Explaining that the physical symptoms are all in the client's head is not therapeutic. Sitting with the client to explore what is really going on is most appropriate nursing response.

A nurse is caring for a client who has neutropenia resulting from chemotherapy. Which precaution would be least appropriate to include when caring for this client?

obtaining rectal temperatures Rectal temperatures should be avoided to prevent trauma and subsequent infection. The nurse should encourage the client to wear a mask to prevent airborne infection. Providing gentle oral care and avoiding razors helps to keep the membranes intact and prevent infection.

Which are core concepts in nursing theory? (Select all that apply.)

Person (client) Environment Health Nursing The person, environment, health, and nursing are all core concepts to nursing theory. Society has not been identified as a core concept.

A client has recently immigrated and is exhibiting symptoms of culture shock. The client reports feeling unaccepted in the new culture. The client states, "I can't do anything right here." What is the priority nursing diagnosis?

Situational low self-esteem related to culture shock and feelings of fear and incompetence The client is experiencing low self-esteem, which is often associated with culture shock. It is situational in nature and will likely improve with cultural assimilation. The client does not indicate powerlessness, spiritual distress, or social isolation.

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data. Nursing diagnoses should always be derived from clusters of significant data, rather than from a single cue. Nursing diagnoses describe client problems that nurses can treat independently and do not require collaboration with other members of the health care team. Therefore, nurses can develop nursing diagnoses without collaborating with physicians or other health care team members.

Which are characteristics of chronic conditions? (Select all that apply.)

Are rarely curable Require lifelong management Have a prolonged course Chronic conditions typically have a slower onset and prolonged course, do not resolve spontaneously, are rarely curable, and require lifelong management. Acute conditions typically have a rapid onset and short course and resolve spontaneously or are curable.

A client reports to a primary health care provider with aggravated chest pain. The health care provider prescribes a stress test. The client tells the nurse about not wanting to take the test and wanting to continue taking medication for now. Understanding that the client is anxious, which action should the nurse take first to provide education needed for this client?

Ask the client "What has your health care provider shared with you about stress tests?" To reassure the client, the nurse should provide education about the stress test so the client can make an informed decision. The nurse should not assume the health care provider has provided complete information about the stress test. By first inquiring with an open-ended question, the nurse allows the client to share his or her knowledge. Then the nurse can provide the education needed, which may include a booklet or other approaches based on the client's learning style. By providing information without first understanding the client's knowledge, the nurse may be repeating something the client already knows.

A nurse overhears a coworker telling a somewhat offensive joke to a client. Which nursing action is indicated?

Discuss the occurrence with the coworker. The first step is to confront the coworker. If the behavior continues or the nurse does not seem to understand the gravity of the mistake, it would be appropriate to discuss the situation with the charge nurse. It makes no difference if the client and coworker have a previous relationship or not, given the unprofessional nature of the incident. The client-nurse boundary should be protected. Apologizing to the client may draw attention to the issue.

The nurse's community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. Which level of health promotion is this an example of?

Primary Primary health promotion and illness prevention is directed toward promoting good health and preventing the development of disease process or injury. Primary-level activities include immunization clinics, providing poison-control information, and education about seat belt and child-safety seat use. Secondary-level activities include screening programs and early identification of disease. Tertiary-level prevention is concerned with returning the client to the optimal function after diagnosis. Medical is not a level of health promotion or illness prevention.

Which nursing actions demonstrate the aim of nursing to facilitate coping? Select all that apply.

Teaching a client and her family how to live with diabetes Assisting a client and his family to prepare for death Providing counseling for the family of a teenager with an eating disorder Coping is another important broad aim of nursing. Nurses facilitate client and family coping for those experiencing altered function, life crisis, and death. Examples of coping would be teaching a client and the client's family about how to live with diabetes. Another example would be assisting a client and the client's family to prepare for death. A third example would be providing counseling for the family of a teenager with an eating disorder. Changing bandages, starting an IV, or teaching a class on an expected health care issue or need would not be examples of the aim of facilitating coping with disability or death.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate?

The outcome is not observable or measurable. The verb in this outcome, "know," is not directly measurable or observable. The verb "demonstrate" would be more appropriate. Educating a client on how to use a nebulizer is an independent nursing action. The outcome is not expressed as a nursing intervention and conditions are not likely necessary for this outcome.

Attending meetings focused on community preparation for natural disasters Developing information sheets to distribute at the county fair Organizing a free influenza immunization clinic

Visiting a client recently discharged from the hospital Conducting an assessment on a family with a terminally ill child A community-based nurse provides care to individuals or families within a community. Examples are visiting clients recently discharged from the hospital and conducting family assessments. A community health nurse focuses on whole populations. Examples are disaster preparation, organizing clinics, and developing education materials for the public.

The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model?

What people believe to be true about their health The Health Belief Model focuses on what people perceive or believe to be true about themselves in relation to their health. The Health Promotion Model focuses on how people interact with their environments, as they pursue health. The Health-Illness Continuum Model focuses on health as a constantly changing state, whereas The Agent-Host-Environment Model explains how certain factors place a person at risk for an infectious disease.

The nurse is caring for a postoperative client, and administers a pain medication prescribed on a PRN basis by the health care provider. What best describes the type of intervention the nurse is demonstrating?

collaborative intervention The administration of a PRN medication requires a health care provider-prescribed intervention (the medication prescription) as well as a nurse-prescribed intervention (determining when the prescription should be carried out and proper administration of the medication); therefore, this action would be considered a collaborative intervention. Nurse-initiated interventions, such as turning and repositioning a client, are described as nurse-prescribed interventions. Health care provider-directed actions are described as health care provider-prescribed interventions. Client advocacy refers to communicating the needs and protecting the needs of the client. Interventions are not normally categorized as being independent or dependent.

When an American client states, "I only want an American doctor," the client is expressing:

ethnocentrism. Viewing one's own culture as superior to all others is ethnocentrism. Cultural relativity is the belief that to understand a person, you must understand that person's cultural context. Cultural pervasiveness refers to how widespread the effects of a culture are. Racism is the belief that one's race is superior to others.

A client asks the nurse for information about Traditional Chinese Medicine. The client specifically asks how Traditional Chinese Medicine might help manage one's chronic migraines. Which response by the nurse is best?

"Acupuncture uses fine needles inserted in the skin to stimulate natural painkillers and has proven to be beneficial in treating chronic migraines." Diagnosis in Traditional Chinese Medicine is based in the balance, or lack thereof, of Yin and Yang. Yin and Yang are both aspects of qi, which is considered a vital life force. Acupuncture has been shown to be an effective way to manage chronic migraine headaches. Meditation is not the only therapy that can be used to treat chronic migraines, and Therapeutic Touch is not part of Traditional Chinese Medicine. The nurse should not recommend botanicals in place of prescribed medications

The nurse determines that a client has not met the goal of consuming at least 80% of each meal served by a designated date. Which response(s) by the nurse would be appropriate regarding this lack of goal attainment? Select all that apply.

"Do you think it is possible that you will be able to eat 80% of the food served here?" "What kinds of things have we been doing to increase your appetite?" "Do you think you could meet the goal if we check on it in one week or so?" The nurse should review the goal to determine whether it is realistic, review the actions taken to move the client toward goal attainment, and consider changing the time line for evaluation. There is no indication that discarding the goal is necessary. By asking whether the client is trying as much as possible to eat 80% of each meal, the nurse infers that the failure to meet the goal is the client's fault. This blame-placing should be avoided.

An informatics nurse specialist is presenting an in-service program for a group of staff nurses on using the electronic health record. As part of the presentation, the nurse specialist is emphasizing the need for maintaining security and privacy of the record. During a break in the program, the nurse specialist overhears a conversation among several of the staff nurses. Which statement would the nurse specialist identify as a cause for concern?

"I always put a sticky note on the computer terminal with my password on it in case I forget it." Nurses are responsible to minimize the risk of harm to clients and providers through both system effectiveness and individual performance. Ensuring secure and appropriate access to clinical systems starts with good management of passwords. Passwords should never be shared or placed in an area where the password could be identified. Putting a password on a sticky note in a visible location such as a computer terminal would be inappropriate. Using different passwords, making the password unique to the individual, and having a password of at least 8 characters in length are appropriate strategies for strong passwords that would keep data safe.

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status?

"My wife's been gone for about 7 months now." The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.

The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment?

"We reviewed your plans for your new diet and medications. Do you have any other questions?" Summarization highlights the important points of a conversation or interaction. Reminding the client that the diet plan and new medications were discussed best summarizes the appointment. The other answers do not review the topics discussed.

A client is meeting with the nurse to discuss options for smoking cessation. Which statement by the nurse is most appropriate for this client?

"What do you see as your biggest hurdle to stopping?" When counseling a client, the focus should be on assisting the client to make one's own decisions, finding ways to reach goals, and supporting the client. The nurse should never give advice, such as reducing cigarette consumption over time or using nicotine patches or gum. Asking open-ended questions that encourage the client to speak freely about the topic at hand and help define goals is the best option. Asking the client which options have previously been tried is a closed question and limits the response to a list of things the client has tried and would not encourage the client to share other information important to form a smoking cessation plan, such as a spouse that smokes.

A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client?

Imbalanced Nutrition, Less Than Body Requirements The correct nursing diagnosis is Imbalanced Nutrition, Less Than Body Requirement. A clear liquid diet for 5 days would not provide adequate nutrition. It does provide about 1,000 calories but it is below the recommended range from 1,600 to 2,400 calories per day for adult women and 2,000 to 3,000 calories per day for adult men. Risk of injury would be related to movement, thoughts, and/or medications. Fluid volume deficit would be inappropriate as the client is consuming a clear liquid diet and that would provide adequate fluid volume but not enough nutrition. Activity intolerance would also be related to movement by the client.

Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within 3 days of physical therapy. Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy meets all of these criteria. "After attending sibling classes, client will be happy about a new baby and demonstrate feeding" is incorrect because it includes more than one client behavior, one of which is not observable or measurable ("be happy"), does not include performance criteria related to how well the client is to demonstrate feeding, and has a vague time frame ("after attending sibling classes"). "By the next clinic visit, client will report taking antihypertensive medication" lacks specificity regarding how often the client should take the medication. "Client will perform complete ostomy care while bathing on the second postoperative day" is likely not attainable within the time frame specified and lacks specificity regarding care the client will provide, making it difficult for the nurse to measure the client's success.

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory?

Cognitive learning theory Cognitive learning theory is the result of people wanting to make sense of the world around them by assimilating and processing information to gain new understandings and insights. Developmental learning theory focuses on considering the patient's physical maturation and abilities, psychosocial development, and cognitive capacity when providing education. Behavioral learning theory focuses on how one learns and unlearns behaviors. Adaptive learning theory explains how learning is optimized when teaching is adapted to the particular learning style of the learner.

The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. What type of data should the nurse review prior to caring for this client? Select all that apply.

Consultations Lab reports Medical history Progress notes X-ray reports Before caring for a client, the nurse should look at all the data previously collected that pertain to the client's condition, including data from consultations, lab and X-ray reports, reports of other therapies (e.g., physical therapy), and other health care professionals working with the client. The financial history is not relevant to the nursing care of the client.

The nurse documents a progress note in the wrong client's electronic medical record (EMR). Which action would the nurse take once realizing the error?

Create an addendum with a correction. If the nurse is using an EMR and the documentation cannot be changed, an addendum will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client

The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach should the nurse plan to implement?

Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray. Those who represent Generations X, Y, and Z may share many learning characteristics. They are or will be technologically literate, having used or grown up with computers, smart phones, and tablet devices. Therefore, it is most appropriate to teach them using some form of multimedia, such as a phone app. The other teaching approaches are less appropriate for this client population.

The nurse is coaching a client who stated a desire to stop smoking without medication. At several sessions to assess the client's success with agreed-upon interventions, the client reports barriers to each action and continues to smoke. What is the best action of the nurse?

Discuss the client's case with a colleague. The focus is not to have the client please the nurse, but to improve client health behaviors. Telling a client that the client's efforts are disappointing is not an effective communication technique and can result in disruption of the therapeutic trust relationship between the nurse and client. The client does not necessarily need therapy just because initial attempts have been unsuccessful. The client desires not to have medication, so arranging for medications goes against the client's wishes in the plan of care. A colleague may shed light on additional actions based on experience with similar issues in the past.

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?

Does this task fall within the scope of a UAP? All of these questions are important, but the priority is whether the task falls within the scope of a UAP. If the answer is no, the rest of the questions are not necessary.

A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting?

Empathy An empathic nurse is sensitive to the client's feelings and problems but remains objective enough to help the client work to attain positive outcomes. Sympathy is the expression of sorrow for someone's situation, involving compassion and kindness. Sympathy shifts the emphasis from the client to the nurse, as the nurse shares feelings and personal concerns and projects them onto the client. Curiosity is a strong desire to know or learn something. Empathy is perceptive awareness of what a client is experiencing. Humility is a modest or low view of one's own importance.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self-care as possible. The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

A nurse is assessing a family and identifying where the family is in the family life cycle. During this assessment, the nurse applies Duvall's theory. Which theory forms the basis for Duvall's theory?

Erikson's theory of psychosocial development Duvall (1985) identified critical family developmental tasks and stages in a family life cycle. Duvall's theory, based on Erikson's theory of psychosocial development, states that all families have certain basic tasks for survival and continuity, as well as specific tasks related to developmental stages throughout the life of the family. Freud, Kohlberg, and Piaget are not associated with Duvall's theory.

In a helping relationship, the nurse would most likely perform what action?

Establish communication that is continuous and reciprocal. In a helping relationship, the nurse would most likely establish communication that is continuous and reciprocal. The goals established for the client must be set in a specific time frame to be effective. The nurse would not encourage the client to independently explore goals. Goal exploration would be done with both the nurse and the client. The relationship that should be established between the nurse and the client is not reciprocal, but rather a formal relationship in which the nurse is the helper and the client is the one being helped.

Which activity best helps the nurse apply theory to practice?

Evidence-based research Evidence-based research is translational research that forms the bridge between theory and practice. Theory development is how desirable change in society is best achieved. Client-focused care is care provided to a client that maintains the client as a functional component of healthcare team. Case management is when care is provided to an individual client by a healthcare provider.

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional value?

Integrity The nurse is demonstrating integrity, which is defined as acting in accordance with an appropriate code of ethics and accepted standards of practice. Seeking to remedy errors made by self or others is an example of integrity. Altruism is a concern for the welfare and being of others. Social justice is upholding moral, legal, and humanistic principles. Human dignity is respect for the inherent worth and uniqueness of individuals and populations.

The nurse is preparing discharge teaching for a client with diabetes. Which information should the nurse include? Select all that apply.

Meal planning Community resources Appropriate use of a glucometer Instructions to follow up with the health care provider The nurse should teach the client with diabetes about meal planning, community resources, appropriate use of a glucometer, and instructions for follow-up care. The social worker will work with the client on methods of payment, if necessary.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment Some people of Chinese descent are modest about having their bodies touched and may see touching as an invasion into their personal space. The nurse should explain what will be done as the assessment progresses and strive to help the client feel as comfortable as possible. However, asking if the client would like the door left closed or opened, is not a priority before starting the assessment. It would be inappropriate to discuss various goals before the assessment is complete. All the information is needed to determine which goals will be most appropriate for each client. It may also be inappropriate to only conduct a focused assessment at this time, depending on the situation and the client. If there are other issues, they should also be evaluated, so that appropriate nursing goals can be determined and the client can receive the best care possible.

Which theory describes, explains, predicts, and controls outcomes in nursing practice?

Nursing theory Nursing theory describes, explains, predicts, and controls outcomes in nursing practice. Systems theory describes how parts interact together. Adaptation theory describes adjustment of living things to other living things and the environment. Developmental theory describes maturation of humans through stages.

A client is reluctant to learn to do finger sticks for home international normalized ratio (INR) monitoring. What is the best statement by the nurse?

Tell me what you know about these tests. Saying something to encourage the client to openly discuss personal issues is the best option. Assessing worry about pain narrows the client's answer to only addressing pain. Asking "why" questions may be considered probing or accusatory and tends to block communication. Generalizing the client's fear is belittling. Assessing the client's perceptions about checking the INR opens up the discussion about the client's barrier to learning to perform this test.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

Avoid more than 250 mg The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family?

A plan designed to support the client physically An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.

A client is asking for the nurse to explain acupuncture. What would the nurse tell the client?

Acupuncture is used to correct disharmony. Acupuncture can be used to correct disharmony or prevent disharmony from developing.

The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?

Administer a high-calorie diet, excluding wheat, rye, and oats. Because this client is underweight and has an allergy to wheat, rye, and oats, administering a high-calorie diet and no wheat, rye, and oats would be the most appropriate intervention to meet the specific needs of this client. Administering a multivitamin, monitoring for allergies, and weighing the client as needed are generalized nursing measures and not specific to this client.

At what period of life do nutrient needs stabilize?

Adulthood Nutrient needs change across the life span in relation to growth, development, activity, and age. Periods of intense growth and development (such as during infancy, adolescence, pregnancy and lactation) increase nutrient needs. Nutrient needs stabilize during adulthood.

A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options.

Clean the incision using the wound cleanser and gauze. Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. Using the scissors, cut one side of the suture below the knot, close to the skin. Grasp the knot with the forceps and pull the cut suture through the skin. Remove every other suture to be sure the wound edges are healed. Apply adhesive closure strips. Incision cleaning prevents the spread of microorganisms and contamination of the wound. Raising the suture knot prevents accidental injury to the wound or skin when cutting. Pulling the cut suture through the skin helps reduce the risk for contamination of the incision area and resulting infection. Removing every other suture allows for inspection of the wound, while leaving an adequate number of sutures in place to promote continued healing if the edges are not totally approximated. Adhesive wound closure strips provide additional support to the wound as it continues to heal.

For a client with a self-care deficit, the long-term goal is that the client will be able to dress oneself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal?

As soon as possible Evaluating the progress of a long-term goal prior to the end date encourages and motivates the client to continue working toward the goal. Waiting until the client is discharged or at the end of the 6 weeks does not provide the client the opportunity to feel a sense of accomplishment and motivation to continue working toward the goal. Only evaluating when the client shows progress may lead to the client becoming discouraged.

The nurse is caring for a 70-year-old client with a fractured wrist. Which is the best method to determine whether the client has retained the information taught?

Ask the client to recall after approximately 15 minutes. Asking a client to recall what has been discussed after approximately 15 minutes helps determine what information the client has actually retained. Observing the change in the client's behavior for a month is not feasible or timely. Testing the client on the health education and information imparted would be time-consuming and unnecessarily involved. Asking the client to self-administer the doses of drug (if even appropriate) would help demonstrate the client's understanding of how to actually administer the drug but not any other aspect of teaching related to a fracture.

A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care?

Asking only the client's parents to be present at the education session Peers are often more influential than parents, nurses, or teachers at this age. It is often appropriate to include a close friend in on the education session. The other answers are developmentally appropriate for a 15-year-old.

A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client?

Assessing importance Using the 0 to 10 scale is a key aspect of assessing importance with motivational interviewing. It helps the nurse to understand the client's feelings toward the recommended activity and can help start a conversation about why the client chose that rating number-and what the nurse could do to increase the number. In the elicit-provide-elicit strategy, the nurse elicits information from the client about a topic, provides teaching on the topic, and then further elicits information from the client. Evoking change talk is when the nurse presents a potential change to the client for consideration. Prioritizing is helping a client determine how to order one's priorities.

A nurse is providing care to a client with end-stage cancer. After weighing the alternatives, the client decides not to participate in a clinical trial offered and is requesting no further treatment. The nurse advocates for the client's decision based on the understanding that the client has the right to self-determination, interpreting the client's decision as reflecting which ethical principle?

Autonomy When respecting autonomy, the nurse supports the client's right to make decisions with informed consent. When promoting the client's well-being, the nurse acts in the best interests of the client. Advocacy is linked to the belief that making choices about health is a fundamental human right that promotes the individual's dignity and well-being. Beneficence is reflected by doing good and promoting what will benefit the client. Justice involves treating each client fairly. Fidelity involves being faithful and keeping promises.

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?

Avoid contact with mosquitoes Biologic vectors are living creatures that carry pathogens that transmit disease. West Nile virus is transmitted via mosquitoes, so the nurse should teach avoidance of mosquitoes to prevent the spread of West Nile virus. A hand sanitizer prevents the spread of a virus spread by contact with surfaces. Self-quarantine is not necessary to prevent the spread of West Nile virus; avoidance of mosquitos is the best way to accomplish this. Blood and body fluid precautions are used to prevent the spread of diseases spread through contact with these fluids. West Nile virus is not spread by airborne or droplet transmission so use of a face mask is not appropriate.

A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply.

Basophils Neutrophils Eosinophils Granulocytes include neutrophils, eosinophils, and basophils. T-lymphocytes and monocytes are agranulocytes.

A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which tort has the nurse committed?

Battery The nurse has committed battery by unlawfully carrying out a procedure that the client had refused. Battery is an assault and includes negligent touching of another person's body or clothes or anything attached to or held by that other person. Assault is the threat of touching another person without the person's consent. Defamation of character in spoken words is called slander. Libel is defamation of character in written words.

Which nursing action associated with successful tube feedings follows recommended guidelines?

Check the residual before each feeding or every 4 to 6 hours during a continuous feeding. The nurse should check the residual before each feeding or every 4 to 6 hours during a continuous feeding. High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia. A closed system is the best way to prevent contamination during enteral feedings. The bowel sounds do not have to be assessed as often as 4 times per shift. Once a shift is sufficient. Food dye should not be added as a means to assess tube placement or potential aspiration of fluid.

A client asks the nurse about the use of healing touch. Which statement regarding healing touch is accurate?

Healing touch does not use injections. Healing touch has been shown to be effective in helping clients relax and improve the healing process. It is not expensive because it involves no special equipment, including insertion of tubes or injections. Aromatherapy and supplemental music are not routinely used in healing touch.

A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action?

Tell the UAP that the RN will assist the UAP with the client's ambulation. The client's safety is always the nurse's primary concern. If the nurse believes that the UAP is unable to safely ambulate the client at this time, the nurse could offer assistance. By assisting the UAP, the nurse ensures the client's safety while still allowing the new UAP to learn. Having a different UAP ambulate the client or instructing the UAP not to ambulate the client does not assist the UAP in learning. Asking the client whether the client feels comfortable having the UAP ambulate the client is inappropriate.

When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model?

Health belief model According to the health belief model, a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. According to the clinical model, health is defined narrowly as the absence of signs and symptoms of disease or injury. The holistic model views individuals as ever-changing systems of energy, and the interaction of a person's mind, body, and spirit within the environment. The high-level wellness model is the recognition of health as an ongoing process toward a person's highest potential of functioning.

The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request?

Identify and recommend some credible websites appropriate to the spouse's learning needs. Web-based resources can be a useful tool in client education, but suitability and accuracy need to be carefully considered. Many online databases exist for health professionals, but these are less likely to be accessible to or appropriate for those outside the health professions. The client has requested online resources, so providing print-based materials is not warranted at this time.

An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?

Identify clients at risk for infection Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, organizations often use this information to identify clients who may be at risk for problems. This area of health care analytics is not involved with determining client satisfaction, evaluating client care, or correlating the client's diagnosis with interventions.

An informatics nurse is assisting with the evaluation of a newly implemented system for electronic documentation of client assessments. The nurse is planning to involve staff nurses in this process. When beginning the evaluation process, the informatics nurse would focus on which area first?

Identifying what will be evaluated In evaluating technology such as a newly implemented electronic documentation system, the informatics nurse would first need to determine what will be evaluated. Once that is determined, the informatics nurse would develop a clearly focused question to help determine what data will need to be collected and how that data would be reported. Next, the informatics nurse would conduct a literature search, followed by a determination of the specific data elements that would be collected.

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client, which promotes communication. If the nurse is standing at the foot or at the side of the client's bed, an authoritative position is established, which does not promote good communication. If both the nurse and the client are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and client should be about 1 m apart.

Which statement best conveys the role of intuition in nurses' problem solving?

Intuition can be a clinically useful adjunct to logical problem solving. Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special "gift" but is thought to be a product of experience and unconscious pattern recognition.

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Knowledge Deficit: Medications related to new medical diagnosis To most appropriately address the client's health problem, the nurse should educate the client about the new medications the physician has prescribed to treat the asthma. Ineffective Airway Clearance refers to the physiologic processes of asthma. There is no evidence of noncompliance. There is no indication that the client is having difficulty dealing with the diagnosis.

The founder of public health nursing is:

Lillian Wald Lillian Wald established a neighborhood nursing service for the sick and poor of the Lower East Side in New York City and was the founder of public health nursing. Clara Barton established the Red Cross in the United States in 1882. Linda Richards was the first trained nurse in the United States. Dorothea Dix was a pioneering crusader for the reform of the treatment of the mentally ill.

A nurse is providing care to a client who is feeling lonely and isolated. In an effort to develop a trusting nurse-client relationship, the nurse exhibits a caring attitude, ensures the client's privacy, and spends time with the client to promote therapeutic communication. The nurse is meeting which category of client needs?

Love and belonging People who believe that their love and belonging needs are unmet often feel lonely and isolated. The nurse addresses this by establishing a nurse-client relationship based on mutual understanding and trust (by demonstrating caring, encouraging communication, and respecting privacy). Physiologic needs are the most basic in the hierarchy of needs and the most essential to life. Safety and security needs have both physical and emotional components: physical safety and security means being protected from potential or actual harm; emotional safety and security involves trusting others and being free of fear, anxiety, and apprehension. Self-esteem needs include the need for a person to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments.

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?

Malpractice The facility and nurse could be charged with malpractice, which is failing to perform (or performing) an act that causes harm to a client. Administering the medication intravenously instead of orally as prescribed has caused harm to a client. Negligence is failing to perform care for a client. When a person threatens to touch a client without consent, it is assault, whereas battery is carrying out the implied threat (assault).

Attracting minorities to the profession of nursing is an important consideration for the future of nursing. Which key historical nursing figure set a precedent in this area?

Mary Elizabeth Mahoney Mary Elizabeth Mahoney set a precedent for minorities in the profession of nursing by becoming the first African American nurse in the United States. Nora Livingston established the first 3-year hospital training in North America. Mary Agnes Snively was a founder of the Canadian Nurses Society. Mary Ann Bickerdyke organized diet kitchens, laundries, and ambulance services.

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?

Modify the plan of care and interventions to meet the client's needs. The nurse should review the plan of care and its implementation periodically and, as needed based on evaluation, modify them to meet the client's needs. Because this client continues to exhibit symptoms identified by the nursing diagnosis, the implementation should be modified to better meet the client's needs and outcomes. Because the original nursing diagnosis appears to be accurate, there is no indication that it falsely identifies the client's problem or that another one is needed. There is no need to reassess the client for more symptoms of deficient fluid volume because it is evident that the client has this problem.

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next?

Notify the physician of the change and document the finding. When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. The nurse should document and report to the physician any new finding of a pulse deficit immediately so that evaluation and follow-up can occur. The nurse should not wait until after rechecking the pulse to document the finding or report it to the physician.

Which statement about laws governing the distribution of controlled substances is true?

Nurses are responsible for adhering to specific documentation about controlled substances. Nurses have specific responsibilities regarding controlled substances, including specific documentation. Violation of controlled substances laws at the workplace is serious and a criminal act. Substance use is treatable, and the objective is to detect and treat the problem early. It does not matter where the nurse obtains the drugs; the nurse is still liable for personal actions.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Obscuring identifiable names of clients and private information about clients on clipboards; placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.

The nurse is teaching a client newly diagnosed with diabetes about the disease, testing, diet, and how to self-administer insulin. The client does not speak the dominant language. What is the appropriate nursing action?

Obtain a medical interpreter. A medical interpreter should always be contacted to ensure accuracy in communication. The nurse can then be assured that client teaching has been appropriately communicated. It is not appropriate, or as reliable and accurate, to have family members translate, to request other health care providers to be present, or to use translation applications.

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?

Obtaining data regarding the amount and frequency of drinking A focused assessment is information that provides more details about specific problems and expands the original database. Obtaining data regarding the amount and frequency of drinking qualifies as a focused assessment. The other actions do not relate to the client's drinking habits or potential for alcohol overuse and thus would not be included in a focused assessment of these issues.

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life-threatening issues. Decreased cardiac output is the only life-threatening problem among the answer options, so it must be the priority.

An informatics nurse specialist is conducting an orientation for the staff of a primary care provider's office about a new web-based tool that they will be implementing. The goal of the tool is to promote patient engagement. The informatics nurse specialist is most likely orienting the staff to which system?

Patient portal A primary patient engagement tool is the patient portal, a web-based tool that can be securely accessed and provides several functions to increase engagement. Telehealth is defined as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Telemedicine involves the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes.

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client?

Prioritize the nursing diagnoses. After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing diagnoses. It is the nurse's responsibility to prioritize the nursing diagnoses, thereby prioritizing the care of the client. Resolved nursing diagnoses should be deleted from the plan of care as soon as they are resolved and replaced with new ones when appropriate. Nursing diagnoses should be written in a nonjudgmental way and in legally advisable terms, not in the nurse's own words. The plan of care is individualized for each client, and therefore the client should be aware of what is included.

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement?

Psychomotor Psychomotor outcomes are those that are related to new skill attainment, such as learning aseptic dressing changes. Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the individual.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?

Review the current infection control protocols. The nurse manager that notes an increase in infection rates should first review the current infection control protocols. Reviewing the protocols can identify if the protocols are appropriate and being implemented by the staff. Prescribing antibiotics to all new residents will not decrease infections rates, but may increase the rate of antibiotic resistant bacteria. Culturing all residents and staff would identify infection, but not decrease the rates. Restricting visitors would not decrease rates.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk?

She may be the victim of cyber-bullying. Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time.

Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family?

Socialization Through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving. Incorporating religious beliefs, values, and attitudes is an example of socialization. Physical functions of the family include providing a safe, comfortable environment necessary for growth and development, rest, and recuperation. The reproductive function of the family is raising children. The affective and coping function of the family involves providing emotional comfort to family members.

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time?

Terminate the plan of care because evaluation reveals that the outcome has been met. The evaluation phase of the nursing process measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. Because evaluation reveals that this client's outcome has been met, it is appropriate to terminate the plan of care. There is no need to modify the plan of care if the outcome is being met.

The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses?

The client has diminished breath sounds. The client's diminished breath sounds can be addressed by the independent nursing interventions of turn, cough, and deep breathe. The temperature, elevated blood pressure, and pain medication will require orders from the physician.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider?

The nurse can accept verbal orders to provide immediate care and record once the client is stable. In most agencies, the only circumstance in which the attending physician, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the physician/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Physicians/providers can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.

Nurses who value client advocacy follow what guideline?

They give priority to the good of the individual client rather than to the good of society in general. Advocacy is the protection and support of another's rights. If the nurse values client advocacy, the nurse would give priority to the good of the individual client rather than to the good of society in general. The nurse would not be demonstrating advocacy if the nurse values the loyalty to an employing institution or to a colleague over the commitment to the client. The nurse demonstrating client advocacy would not choose the claims of the client's well-being over the claims of the client's autonomy. The nurse would not make decisions for clients who are uninformed concerning the client's rights and opportunities.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?

To assure the IV solution is appropriate for this administration The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.

An older adult client has diminished thirst sensation. What teaching will the nurse give the client to help the client get enough fluid?

Try drinking something savory like broth. Generally, thirst signals the need for water and encourages a person to drink. This sensation often is diminished in older adults. There are many sources of fluids, thus clients do not have to drink only plain water to get hydrated. Coffee, tea, fruit juices, fruits, and vegetables all contain water. Clients should be advised to steer away from sugary drinks and alcohol, as these fluids are not beneficial. Trying a savory drink may be an option. Clients should experiment with both hot and cold drinks. Both are equally easy to drink, based on client preference.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old.

The nurse works in an urban hospital and cares for a diverse population of clients. Which action(s) by the nurse demonstrates the delivery of culturally sensitive care to clients? Select all that apply.

asking the client questions regarding health care beliefs related to the client's culture allowing the client to keep a religious necklace on until going into the operating room integrating the client's cultural practices when assisting with the creation of the plan of care There are many ways in which nurses should deliver culturally sensitive care, but the priority is to understand the difference in culture and ethnicity and integrate these beliefs into the care delivery system. Asking questions related to culture is important since not all cultural groups follow a general belief practice. This should be considered whenever the plan of care is being developed. Allowing a client to wear a religious necklace until going into the operating room and keeping it in a safe place to be returned after a procedure is a demonstration of cultural sensitivity. Implying that a cultural group should adapt to the Anglo-American way is not culturally sensitive. Not all cultural groups respond to direct eye contact and the nurse should be aware of how this may be perceived.

The nurse is caring for a postoperative client. The health care provider has written a prescription for a pain medication, and the prescription gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called:

collaborative functioning. Nurses manage collaborative problems using both nurse- and health care provider-prescribed interventions to reduce the risk of complications. In this situation, the nurse is not operating authoritatively or independently, but within the parameters established by the health care provider. The nurse is not merely acting in an assistive capacity, as the nurse is performing interventions in the absence of the health care provider.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

Identifying the kind and amount of nursing services required is a possible solution for:

inadequate staffing. A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who fails to communicate needs. Educating the client to become an assertive health care consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period. An initiative to focus on quality improvement is a possible solution to nurses frustrated with substandard care. Reviewing task assignments and work schedules is a possible solution to bored nurses.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis. Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:

premature closure. Premature closure is when the nurse selects a nursing diagnosis before analyzing all of the pertinent information in the client's case. The nurse did not investigate any other information in this case before making a diagnosis. Inconsistent cues occur when the meaning attached to one cue may be altered based on another cue. The nurse in this case only considered one cue, so inconsistent cues could not be the correct answer. Clustering of cues is a clustering of data; this nurse has only one cue, so the nurse cannot cluster data or interpret data clusters.

A student nurse is preparing a poster for a health fair which will compare the various types of methods used to pay for health care. Which factor(s) should the student include in the managed care section? Select all that apply.

uses resources efficiently provides education to reduce risk of disease bargains with providers for reasonably priced quality care Managed care uses several techniques including using resources efficiently, providing education to reduce risk of disease, and bargaining with providers for reasonably priced quality care. Medicare instituted the DRG technique. Capitation is the process of the insurance company providing the health care provider a set amount per member whether the services are used or not.