HESI FUNDAMENTALS

The nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." Which does this nurse's comment reflect? A. Demonstration of a personal bias B. Problem-solving based on assessment C. Determination of client acuity to set priorities D. Consideration of the complexity of client care

A. Demonstration of a personal bias Rationale: When nurses make judgmental remarks and client needs are not placed first, the standards of care violated and quality of care is compromised. Assessments would be objective, not subjective and biased. There is no information about the client's acuity to come to this conclusion regarding priorities. The statement does not reflect information about the complexity of care.

What is the most important skill of the nurse leader? A. Priority setting B. Time management C. Clinical decision-making D. Clinical care coordination

D. Clinical care coordination Rationale: The most important leadership skill for the nurse leader is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components in clinical care coordination.

The nurse is conducting a client interview. Which response by the nurse is an example of back channeling? A. "All right, go on..." B. "What else is bothering you?" C. "Tell me what brought you here." D. "How would you rate your pain on a scale of 0 to 10?"

A. "All right, go on..." Rationale: Back channeling involves the use of active listening prompts such as "Go on...," "all right,' and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his or her health concerns in their own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? A. Tubing injection port B. Distal end of the tubing C. Urinary drainage bag D. Catheter insertion site

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

Which degree of edema will result in a 6-mm deep indentation upon pressure application? A. 4+ B. 3+ C.2+ D. 1+

B. 3+ Rationale: The depth of pitting edema determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

Which is appropriate for the nurse to include in the education of the ethical principal of nonmaleficence to a group of nursing students? A. Treat all clients equitably and fairly B. Act in ways to prevent harm to clients C. Tell the client the truth about their health D. Help the clients make informed choices

B. Act in ways to prevent harm to clients Rationale: Nonmaleficence means to act in ways that prevent client harm or even the risk of harm. Telling the truth to clients about their health refers to veracity. Helping clients make informed choices promotes autonomy. Justice involves treating all clients equitably and fairly.

The nurse noted the respiratory rate as regular and slow while assessing a client. Which would be the condition of the client? A. Apnea B. Bradypnea C. Tachypnea D. Hyperpnea

B. Bradypnea Rationale: In bradypnea the breathing rate is regular, but it is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.

Which variable is an internal variable? A. Family practices B. Emotional factors C. Cultural background D. Socioeconomic factors

B. Emotional factors Rationale: Emotional factors are internal variables. Family practices, cultural background, and socioeconomic factors are external variables.

The nurse changed a dressing on a client's wound with vancomycin-resistant enterococci (VRE). Which step would the nurse take to ensure proper disposal of the soiled dressing? A. Place the dressing in the bedside trash can. B. Place the dressing in a red bag/hazardous material bag. C. Contact environmental services personnel to pick up the dressing. D. Transport the dressing to the laboratory to be placed in the incinerator.

B. Place the dressing in a red bag/hazardous material bag. Rationale: Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; thus the dressing should be placed in a red bag or hazardous materials bag. The soiled dressing should not be placed in a single bag and left in the trashcan. Infection control is every health care worker's responsibility, not just environmental services'. The laboratory is not responsible for disposal of hazardous wastes that occur as a result of normal nursing activities.

Which chemical buffers excessive acetoacetic acid? A. Potassium B. Sodium bicarbonate C. Carbon dioxide D. Sodium choloride

B. Sodium bicarbonate Rationale: Sodium bicarbonate is a base and one of the major buffers in the body. Potassium, a cation, is not a buffer; only a base can buffer an acid. Carbon dioxide is carried in aqueous solution as carbonic acid; an acid does not buffer another acid. Sodium chloride is not a buffer; it is a salt.

Which is the most therapeutic response by the nurse to a client who is joking about dying? A. "Why are you always laughing?" B. "Your laughter is a cover for your fear." C. "Does it help to joke about your illness?" D. "The person who laughs on the outside cries on the inside."

C. "Does it help to joke about your illness?" Rationale: The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

The registered nurse (RN) is teaching the student about providing care to an older adult with dementia. Which statement by the nursing student indicates a need for further education? A. "I should serve food that is easy to eat." B. "I should assist the client with eating." C. "I should monitor weight and food intake once a month." D. "I should offer food supplements that are tasty and easy to swallow."

C. "I should monitor weight and food intake once a month." Rationale: The nurse would monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse would serve food that is easy to eat and provide assistance with eating. The nurse would also offer food supplements that are tasty and easy to swallow.

How would the nurse prevent footdrop in a client with a leg cast? A. Encourage complete bed rest to promote healing of the foot. B. Place the foot in traction. C. Support the foot with 90 degrees of flexion. D. Place an elastic stocking on the foot to provide support.

C. Support the foot with 90 degrees of flexion. Rationale: To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.

An 80-year-old client is admitted to the hospital with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated. Which response by the nurse is correct? A. The body's fluid needs decrease with age because of tissue changes." B. "Access to fluid may be insufficient to meet the daily needs of the older adult." C. "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." D. "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased."

D. "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased." Rationale: For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake.

A client presents to the health care facility with abdominal pain. Which question would the nurse ask the client to obtain information about concomitant symptoms? A. "Can you describe the pain?" B. "Where exactly do you feel the pain?" C. "Which activities make the pain worse?" D. "What other discomfort do you experience?"

D. "What other discomfort do you experience?" Rationale: Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain. The nurse assess the quality of the pain by asking the client to describe it. The nurse gathers information about the location of the illness by asking the client to identify the exact location. The nurse tries to understand the precipitating factors by asking the client about the activities that aggravate the pain.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. Which is it important for the nurse to inform the client of? A. The client is acting irresponsibly. B. The client is violating the hospital policy. C. The client must obtain a new healthcare provider for future medical needs. D. The client must accept full responsibility for possible undesirable outcomes

D. The client must accept full responsibility for possible undesirable outcomes Rationale: The client has the right to self-determination, which includes refusing medical treatment. However, if the client does so, he or she must accept full responsibility for the illness and possible injury or undesirable outcomes. Health care professionals have a responsibility to inform the client and, if possible, have the client sign an informed waiver or a leaving against medical advice document. Acting irresponsibly is a subjective assumption. The client may be violating the hospital policy; however, if the client is deemed competent, he or she has the right to refuse treatment. Leaving against medical advice does not mean that the primary health care provider will refuse to provide care to the client in the future.

What pulse site is used to perform Allen test? A. Ulnar B. Brachial C. Femoral D. Dorsalis pedis

A. Ulnar Rationale: The ulnar pulse is used to perform Allen test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

The nurse records the client's weight and body mas index (BMI) at a healthy range, but the client states, "I wish I were as thin as my coworkers." Which culturally bound condition is the client at risk for? A. Neurasthenia B. Anorexia nervosa C. Shenjing shuairuo D. Ataque de nervios

B. Anorexia nervosa Rationale: Anorexia nervosa is a Western culture-bound eating disorder characterized by obsession with body image. A client who continues to follow weight loss diets despite being a healthy weight may be at risk for malnutrition. The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses of a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latino-Caribbean culture-bound syndrome and is not associated with body image.

Which assessment is expected when a client is placed in the lithotomy position during physical examination? A. Heart B. Rectum C. Female genitalia D. Musculoskeletal system

C. Female genitalia Rationale: Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indication in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

Which variable is an example of an external variable? A. Spiritual factors B. Developmental issues C. Socioeconomic factors D. Perception of functioning

C. Socioeconomic factors Rationale: Socioeconomic factors are considered to be external variables. Spiritual factors, developmental issues, and the perception of functioning are internal variables.

Which activity demonstrates fine motor skills in infants aged 2 to 4 months? A. Turning from side to back B. Sitting erect using support C. Showing good head control D. Bringing objects from hand to mouth

D. Bringing objects from hand to mouth Rationale: Bringing objects from hand to mouth indicates fine motor skills observed in infants aged 2 to 4 months. Turning from side to back, sitting erect using support, and showing good head control are gross-motor skills.

Which statement is true for collaborative problems in a client? A. They are the identification of a disease condition B. They include problems treated primarily by nurses C. They are identified by the primary health care provider D. They are identified by the nurse during the nursing diagnosis stage.

D. They are identified by the nurse during the nursing diagnosis stage. Rationale: The nurse assesses the client to gather information for reaching diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines, such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary health care provider based on the results of diagnostic tests.

Which is the most important nursing action involved in caring for a client receiving medications? A. Administering the medication B. Teaching about the medications C. Ensuring adherence to the medication regimen D. Evaluating the client's ability to self-administer medications

A. Administering the medication Rationale: The most important part of the nursing practice regarding medication is administering the medications. Administering medications safely requires an understanding of the legal aspects of health care, pharmacology, pathophysiology, human anatomy, and mathematics. Teaching about the medications, ensuring adherence to the medications, and evaluating the client's ability to self-administer medications are responsibilities of the nurse performed before or after the administration of medicines.

Which critical thinking skill will help a student nurse avoid making assumptions about clients? A. Analysis B. Inference C. Evaluation D. Explanation

A. Analysis Rationale: Use of analysis allows the student nurse to be open-minded while looking at the client's information and to avoid making assumptions. Inference skills focus on the meaning of the findings and its significance. Evaluation involves looking at all situations objectively and using criteria to determine the results of nursing actions. Explanation is the act of supporting your findings and conclusions as well as using knowledge and experience to choose strategies to use in the care of clients.

Which intervention would the nurse expect to implement to alleviate anxiety for a preoperative client? A. Attempt to identify the client's concerns. B. Reassure the client that the surgery is routine. C. Report the client's anxiety to the health care provider D. Provide privacy by pulling the curtain around the client.

A. Attempt to identify the client's concerns. Rationale: The nurse would assess the situation before planning an intervention. Reassuring the client that the surgery is routine minimizes concerns and cuts off communication. Reporting the client's anxiety to the health care provider is premature; more information is needed. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse? A. Bruit B. Ectropion C. Entropion D. Borborygmi

A. Bruit Rationale: A bruit is audible vascular blowing sound associated with turbulent blood flow through carotid artery. Ectropion is a condition in which the eyelid is turned outward away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines.

When a client expresses anxiety about being given anesthesia, which team member should sit with the person and provide comfort during the induction? A. Circulating nurse B. Surgical assistant C. Registered nurse first assistant D. Certified registered nurse anesthetist

A. Circulating nurse Rationale: The circulating. or nonsterile, nurse would sit with the client to provide comfort during the induction. The surgical assistant and registered nurse first assistant will be assisting the surgeon during the procedure and will be scrubbed and sterile. The certified registered nurse anesthetist will be focused on providing medications to the client and cannot sit with the client during induction.

A Spanish-speaking client is being cared for by English-speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client? A. Contact an interpreter provided by the hospital B. Contact the client's family member to translate for the client. C. Communicate with the client using Spanish phrases the nurse learned in a college course. D. Communicate with the client with the use of a hospital-approved Spanish dictionary.

A. Contact an interpreter provided by the hospital Rationale: Interpreters provided by the health care organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate health care information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? A. Don an N95 respirator mask before entering the room B. Put on a permeable gown each time before entering the room C. Implement contact precautions and post appropriate signage. D. After finishing with client care, remove the gown first and then remove the gloves

A. Don an N95 respirator mask before entering the room Rationale: An N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions, not contact precautions are required. When finished with care, gloves would be removed first because they are the most contaminated.

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? A. Elevate the head of the bed between 30 and 45 degrees B. Decrease flow rate at night C. Check for residual daily D. Irrigate regularly with warm tap water

A. Elevate the head of the bed between 30 and 45 degrees Rationale: To prevent aspiration, the nurse would keep the head of the bed elevated between 30 and 45 degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of skin breakdown. Decreasing low rate, checking for residual, and irrigating regularly will not prevent aspiration.

The nurse is discussing discharge plans with a client. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." Which interviewing technique did the nurse use? A. Exploring B. Reflecting C. Refocusing D. Acknowledging

A. Exploring Rationale: Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion.

Which statements have been correctly stated about Nightingale's theory of nursing? Select all that apply. A. Focus of nursing is caring through the environment B. Limits nursing to the administration of medications and treatment C. Suggests that every nurse would know all about the disease process D. Oriented toward provided fresh air, light, warmth, cleanliness, quiet, and adequate nutrition E. Focuses on helping the client deal with the symptoms and changes in function related to an illness.

A. Focus of nursing is caring through the environment D. Oriented toward provided fresh air, light, warmth, cleanliness, quiet, and adequate nutrition E. Focuses on helping the client deal with the symptoms and changes in function related to an illness. Rationale: Nightingale's theory of nursing focuses on nursing by caring through the environment. Nightingale's theory is oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness. Nightingale's theory does not limit nursing to the administration of medications and treatment. Nightingale's theory suggests that nurses do not need to know all about the disease process. which differentiates nursing from medicine.

Which therapeutic communication technique is used when the nurse and a client have a conversation and the client begins to repeat the conversation to her- or himself? A. Focusing B. Clarifying C. Paraphrasing D. Summarizing

A. Focusing Rationale: Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.

The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? A. Handwashing before and after providing client care B. Cleaning all equipment with an approved disinfectant after use C. Wearing personal protective equipment (PPE) when providing client care D. Using medical and surgical aseptic techniques at all times

A. Handwashing before and after providing client care Rationale: Hand washing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all the other interventions are acceptable procedures and may assist in preventing the spread of infection, none are as effective as hand washing.

Which is the goal of school health nursing programs? A. Health promotion B. Disease management C. Chronic care management D. Environmental surveillance

A. Health promotion Rationale: The goal of school health nursing programs is health promotion through the school curriculum. A class on nutritional planning for parents contributes to health promotion. Disease management is one of the many programs of community health centers. These centers provide primary care to a specific client population within a community. Nurse-managed clinics provide nursing care with a focus on acute and chronic care management. The occupational health nurse may conduct environmental surveillance for health promotion and accident prevention in the work setting.

To ensure a client and visitor safety during transport of a client with influenza A (H1N1) for a computed tomography, the nurse would take which precaution? A. Place a surgical mask on the client. B. Other than standard precautions, no additional precautions are needed. C. Minimize close physical contact. D. Cover the client's legs with a blanket.

A. Place a surgical mask on the client. Rationale: Nurses would provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their rooms. Special precautions such as face masks would be taken to decrease the risk for further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? A. Planning B. Evaluation C. Assessment D. Implementation

A. Planning Rationale: The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of a nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.

How are profits used in a for-profit health care organization? A. Profits are paid out to shareholders B. Profits are used to buy new equipment C. Profits are used to build additional facilities D. Profits are invested in improving health care services

A. Profits are paid out to shareholders Rationale: Health care organizations can be classified as for-profit and not-for-profit based on how the profits are distributed. In a for-profit organization, the profits are generated for the shareholders. In a not-for-profit organization, the profits are used to buy new equipment, build additional facilities, and improve health care services.

Which would the nurse document for a client with drooping of the eyelid over the pupil? A. Ptosis B. Ectropion C. Entropion D. Nystagmus

A. Ptosis Rationale: Eyelids that droop over the pupil is called ptosis, which is how the nurse would document the finding. Ectropion is when the eyelid margins turn out. Entropion is similar, but is when the eyelid margins turn in and sometimes can cause irritation of the conjunctiva and cornea. Nystagmus is an involuntary oscillation of the eyes, and usually occurs after an eye injury.

Which nursing practice is associated with a self-regulation skill? A. Reflecting on one's experience B. Reflecting on one's own behavior C. Supporting one's finding and conclusions D. Clarifying any data that one is uncertain about

A. Reflecting on one's experience Rationale: Self-regulation involves reflecting on the nurse's experience. Evaluation involves reflecting on the nurse's own behavior. Explanation involves supporting findings and conclusions. Interpretation involves clarifying any data about which the nurse is uncertain.

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? A. Shift of fluid into the interstitial spaces B. Weakening of the cell wall C. Increased intravascular compliance D. Increased intracellular fluid volume.

A. Shift of fluid into the interstitial spaces Rationale: Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathological reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.

The nurse at the well-baby clinic is assessing the gross motor skills of a 5-month-old infant. Which finding is a cause for concern? A. The baby has a head lag when pulled to sit. B. The baby can turn from the side to the back. C. The baby can turn from the abdomen to the back. D. The baby supports much of their own weight when they are pulled to stand.

A. The baby has a head lag when pulled to sit. Rationale: A normal 5-month-old infant should be able to sit up without a head lag. This finding should cause the nurse to conduct a further assessment. A baby should be able to turn from the side to the back by 4 months of age. At 5 months of age, the baby should be able to turn from the abdomen to the back. The baby should be able to support much of his or her own weight when pulled to stand by the age of 5 to 6 months.

A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container? A. The local hazardous waste collection site B. The regular household trash C. The local health department for disposal D. The Environmental Protection Agency through the mail

A. The local hazardous waste collection site Rationale: Each state has its own waste management guidelines for proper disposal of sharps containers, as well as hazardous waste collection sites. Clients cannot place needles in the regular household trash because sharps are considered medical waste. The local health department does not collect sharps containers. Sharps containers are not mailed directly to the EPA.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? A. Their gag reflex has returned B. They are confused due to anesthesia C. They are nauseated and want to vomit D. Their airway is becoming obstructed

A. Their gag reflex has returned Rationale: The ability to spit out the oral airway indicates that the normal gag reflex has returned and the client can protect his or her airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit out the airway does not mean that the client is nauseated. An oral airway is meant to keep the airway patent; it may not obstruct the airway.

A client is likely to undergo reconstructive surgery for which purpose? A. To restore function and/or appearance B. To replace an organ or tissue C. To relieve or reduce symptoms D. To remove or excise an organ or tissue

A. To restore function and/or appearance Rationale: The main function of reconstructive surgery is to restore function and/or appearance. This type of surgery includes plastic surgery, a term that is interchangable with reconstructive surgery. In reconstructive surgery, repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known as transplant; surgery to relieve or reduce symptoms is known as palliative; and surgery to remove or excise an organ or tissue is known as resection.

Which approach is a comforting approach that communicates concern and support? A. Touch B. Listening C. Knowing the client D. Providing a positive presence

A. Touch Rationale: Touch is a comforting approach that involves reaching out to clients to communicate concern and support. Listening is a critical component of nursing care and is necessary for meaningful interactions with clients. Knowing the client comprises both the nurse's understanding of a specific client and his or her subsequent selection of interventions. Providing presence is a person-to-person encounter that conveys closeness and a sense of caring.

According to Quality and Safety Education for Nurses (QSEN), which defines patient centered care? A. Understanding that the client is the source of control when providing care B. Functioning effectively within nursing and interprofessional teams to deliver quality care C. Using data to evaluate outcomes of care processes and designing methods to improve health care D. Minimizing the risk for harm to clients and health care workers through improved professional performance

A. Understanding that the client is the source of control when providing care Rationale: The QSEN competency called patient-centered care requires the nurse to understand that the client is the source of control. The nurse would respect the values, beliefs, and preferences of the client to provide quality care. The QSEN competency called teamwork and collaboration states that the nurse would function effectively within nursing and interprofessional teams to provide quality care. Quality improvement involves using data to evaluate the outcomes of care processes and design methods to improve the health care delivery system. Safety focuses on minimizing the risk for harm to clients and health care workers through improved professional performance.

Which activity by the community nurse is an illness prevention strategy? A. Encouraging the client to exercise daily B. Arranging an immunization program for chicken pox C. Teaching the community about stress management D. Teaching the client about maintaining a nutritious diet

B. Arranging an immunization program for chicken pox Rationale: An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain his or her present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.

Which professional standard is important for critical thinking? A. Logical thinking B. Evaluation criteria C. Accurate knowledge D. Relevant information

B. Evaluation criteria Rationale: An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Which critical thinking skill refers to the use of knowledge and experience to choose effective strategies for client care? A. Evaluation B. Explanation C. Interpretation D. Self-regulation

B. Explanation Rationale: Explanation involves using knowledge and experience to choose strategies to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.

During a home visit, the nurse finds that a healthy older person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. Which inference about the client would the nurse make from these findings? A. Not motivated B. Intrinsically motivated C. Extrinsically motivated with self-determination D. Extrinsically motivated without self-determination

B. Intrinsically motivated Rationale: An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy on suggestion or pressure created by other individuals.

Which is true about prescriptive theory? A. It is nonspecific. B. It focuses on medication C. It is seen in the Neuman Systems model D. It focuses on the phenomenon of an event

B. It focuses on medication Rationale: Prescriptive theory is focused on the prescribed medication under particular circumstances. Prescriptive theory is nursing-intervention specific and does not cover a wide range of nursing practices. The Neuman systems model is an example of a grand theory. Prescriptive theory is focused on a client's abilities to cope with situations.

Which is an appropriate action for the registered nurse regarding assisted suicide? A. Nurses may have an open attitude toward the client's end of life. B. Nurses' participation in assisted suicide violates the code of ethics. C. Nurses may listen to the client's expressions of fear and attempt to control the client's pain. D. Nurses can participate in assisted suicide only if the individual could make an oral and written request.

B. Nurses' participation in assisted suicide violates the code of ethics. Rationale: According to the American Nurses Association (ANA), the nurse's participation in assisted suicide would violate their code of ethics. According to the American Association of Colleges of Nursing (AACN) and the International Council of Nurses, the nurse may have an open attitude toward the client's end of life. According to the AACN and the International Council of Nurses, nurses may listen to the client's expressions of fear and to attempt to control the client's pain. According to the Oregon Death with Dignity Act (1994), the primary health care provider in the state of Oregon can participate in assisted suicide only if an individual with terminal disease makes an oral and written request to end his or her life in a humane and dignified manner.

Which position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties? A. Sims position B. Prone position C. Supine position D. Knee-chest position

B. Prone position Rationale: Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress? A. Sharing hope B. Sharing humor C. Sharing empathy D. Sharing observations

B. Sharing humor Rationale: Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses would recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client communicate without the need for extensive questioning, focusing, or clarification.

Which statement defines the term "family resiliency"? A. Each family is unique B. The family has an ability to cope with stressors C. An interfamilial structure and support system exist. D. The family has the ability to transcend lifestyle changes

B. The family has an ability to cope with stressors Rationale: Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults; however, the family is capable of transcending inevitable lifestyle changes.

What is the role of the case manager in a health care organization? A. To delegate work on the unit suitably B. To follow up with the client after discharge C. To provide direct care for the client at the bedside D. To unite the strategic direction of the organization

B. To follow up with the client after discharge Rationale: A case manager is an advanced practice nurse who coordinates a client's acute care in the hospital and follows up with the client after discharge. The nurse manager delegates work appropriately to the nursing staff on the unit. A registered nurse provides direct care to the client at the bedside. The nurse executive is often the vice president or strategic director of nursing in a health care organization.

A 50-year-old client seen for a routine physical asks why a stool specimen for occult blood testing has been ordered. What is the correct nursing response? A. "You will need to ask your health care provider; it is not part of the usual tests for people your age." B. "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." C. "It is performed routinely starting at your age as part of an assessment for colon cancer." D. "There must have been a positive finding after a digital rectal examination performed by your health care provider."

C. "It is performed routinely starting at your age as part of an assessment for colon cancer." Rationale: The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40 years. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

Which of these programs is least likely to focus on medication delivery process modification? A. Evaluation research B. Quality improvement C. Experimental research D. Performance improvement

C. Experimental research Rationale: Experimental research is least likely to focus on medication delivery process modification. Quality improvement, evaluation research, and performance improvement are all likely to focus on medication delivery process modification to make the process better for the client.

The nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty? A. Caring B. Veracity C. Advocacy D. Confidentiality

C. Advocacy Rationale: The nurse has a professional duty to advocate for a client by promoting what is best for the client. This is accomplished by ensuring that the client's needs are met and by protecting the client's rights. Caring is a behavioral characteristic of the nurse. Veracity relates to the habitual observance of truth, fact, and accuracy. Confidentiality is an ethical principle and legal right that the nurse will hold secret all information relating to the client unless the client gives consent to permit disclosure.

Which describes the role of the nurse in this situation when he or she informs the health care provider the client is requesting pain medication after surgery? A. Educator B. Manager C. Advocate D. Administrator

C. Advocate Rationale: The nurse acts as the client advocate by speaking to the primary health care provider on behalf of the client. The nurse acts as an educator while teaching the client facts about health and the need for routine care activities. The nurse manager uses appropriate leadership styles to create a nursing environment for client-centered care. The nurse administrator manages client care and delivery of specific nursing services within a health care agency.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? A. Red blood cell count B. Sputum culture C. Arterial blood gas D. Total hemoglobin

C. Arterial blood gas Rationale: Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

Which nursing process would the nurse undertake when collecting the medical history of a client? A. Diagnosis B. Evaluation C. Assessment D. Implementation

C. Assessment Rationale: The documentation of the client's information is part of an assessment. The nurse will collect all the relevant medical data of the client to help the health care provider understand the client's history and make an accurate diagnosis. During diagnosis, the collected data is analyzed to find out the client's problems or issues. Evaluation is the process to see if the expected outcomes of the treatment are achieved or not. Before an evaluation, a plan is made to solve all the client's problems and then the plan is implemented.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, which would the nurse expect to find? A. Large area of petechiae B. Red birthmark that has recently become lighter in color C. Brown or black mole with red, white, or blue areas D. Patchy loss of skin pigmentation

C. Brown or black mole with red, white, or blue areas Rationale: Melanomas have an irregular shape and lack of uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades with time. A patchy loss of skin pigmentation indicates vitiligo.

Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of electronic health records (EHRs)? A. National Institutes of Health (NIH) B. American Medical Informatics Association (AMIA) C. Center for Medicare and Medicaid Services (CMS) D. Health Information Management Systems Society (HIMSS)

C. Center for Medicare and Medicaid Services (CMS) Rationale: CMS rules specify how health care facilities and providers make meaningful use of the EHRs and technologies to receive payment from Medicare and Medicaid. The NIH uses translational bioinformatics for medical research. The AMIA and HIMSS have been involved in identifying nursing informatics competencies.

A client with chronic renal failure stops responding to the treatment. On examination, the primary health care provider determines that the client is terminally ill. Which is the correct nursing intervention in this situation? A. Suggest that the family members get a second opinion. B. Suggest that the family members continue to try different treatments C. Encourage the family members to provide palliative care to the client. D. Inform the family members that the disease is no longer curable and the client will die shortly.

C. Encourage the family members to provide palliative care to the client. Rationale: Clients who are terminally ill and no longer respond to treatment are in need of palliative care. Palliative care promotes client comfort and provides important interventions to support the client and family at the end of life. There is no need to get a second opinion from another primary health care provider, because the client is terminally ill. Continuing to attempt different treatments until the death of the client may cause more client suffering. It is not advisable to inform the family members that the client will die soon because it may lead to emotional stress. The palliative care team will help prepare the family for the client's death.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? A. Analysis B. Inference C. Explanation D. Interpretation

C. Explanation Rationale: Explanation requires knowledge and experience for choosing strategies for care for clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of interference is associated with noticing relationships in the findings. Interpretation is associated with ordered data collection.

Which critical thinking skill is being used when the nurse applies knowledge and experience to client care? A. Analysis B. Evaluation C. Explanation D. Interpretation

C. Explanation Rationale: When the nurse is using experience to care for clients, the critical thinking skill of explanation is being applied. Analysis is applicable when the information is collected with an open mind. Evaluation is applicable when the information is used to determine nursing actions. Interpretation is involved when orderly data is collected.

A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client? A. It relieves bronchial spasms B. It increases the depth of respirations C. It loosens pulmonary secretions D. It expels carbon dioxide from the lungs

C. It loosens pulmonary secretions Rationale: Postural drainage and percussion, also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficultly and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate the removal of carbon dioxide from the lungs.

The nurse has provided discharge instructions to a client who received a prescription for a walker. The nurse determines that the teaching has been effective when the client does which? A. Picks up the walker and carries it for short distances B. Uses the walker only when someone else is present C. Moves the walker no more than 12 inches (30.5 cm) during use D. States that a walker will be purchased on the way home from the hospital

C. Moves the walker no more than 12 inches (30.5 cm) during use Rationale: Safety is always a consideration when teaching a client how to use an assistive device. The correct procedure regarding using a walker is to move the walker no more than 12 inches (30.5 cm) in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan it needs to be provided before the client leaves the hospital.

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues? A. Palpation B. Inspection C. Percussion D. Auscultation

C. Percussion Rationale: Percussion is the process of tapping the body parts with the fingers of hands to determine the consistency and borders of the body organs. Palpation is the act of feeling with the hand by applying pressure to the body surface to determine the condition of the skin and underlying tissues. Inspection is the process of visual observation of the body during physical examination. Auscultation means to listen to the internal sounds of the body.

A client on hospice care is receiving palliative treatment. Which is the goal of palliative care for this client? A. Restore the client's health B. Promote the client's recovery C. Relieve the client's discomfort D. Support the client's significant others.

C. Relieve the client's discomfort Rationale: Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client's discomfort.

The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern is this characteristic of? A. Relapsing B. Sustained C. Remittent D. Intermittent

C. Remittent Rationale: In a remittent pattern, fever spikes and falls without returning to normal temperature levels. Periods of febrile episodes coupled with periods of acceptable temperature values are called relapsing pattern. A constant body temperature continuously above 100.4 F (38 C) with little fluctuation refers to a sustained pattern. In an intermittent pattern, fever spikes are interspersed with normal temperature levels.

Which component of ethical decision-making refers to the duties and activities the nurse is employed to perform? A. Authority B. Autonomy C. Responsibility D. Accountability

C. Responsibility Rationale: Responsibility refers to all duties and activities the nurse is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

Which developmental changes require the nurse's assessment in a 12-year-old female? A. Motor skills B. Visual acuity C. Skeletal growth D. Hormonal changes

C. Skeletal growth Rationale: Girls around the age of 12 years may develop scoliosis (a lateral curvature of the spine); therefore skeletal growth should be evaluated. Motor skills should be evaluated in preschool children. Visual acuity should be evaluated in school-age children. Hormonal changes should be evaluated in adolescents.

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the correct response by the nurse? A. "You must keep up a strong appearance for him now." B. "I think he'd have difficulty dealing with that now." C. "Don't you think he knows that without you telling him?" D. "You should share your feelings with him while you can."

D. "You should share your feelings with him while you can." Rationale: It is difficult to work through a loss; however, encouraging the sharing of feelings helps both parties feel better about having to let go. The response, "You must keep up a strong appearance for him" impedes the work of acceptance of one's finality and the use of the remaining time to the best advantage. There is no evidence to suggest that the client cannot cope with these emotions; the response, "I think he'd have difficulty dealing with that now" denies that this is a time for closeness and honesty. The response, "Don't you think he knows that without you telling him?" is demeaning, closes off communication, and does not foster the expression of feelings.

The nurse notes that a client has mild hypothermia based on which body temperature? A. 29 C B. 30 C C. 33 C D. 35 C

D. 35 C Rationale: Hypothermia occurs when the body temperature falls below 36.2 C. Based on the severity, it is classified as mild, moderate, and severe. Mild hypothermia refers to a body temperature of 34 C to 36 C (93.2 F-96.8 F). In this case, the client's body temperature is 35 C, which indicates mild hypothermia. Moderate hypothermia refers to a body temperature of 30 C to 34 C (86 F-93 F), and severe hypothermia refers to a body temperature below 30 C (86 F). The client does not have severe hypothermia; therefore, the client does not have a body temperature of 29 C. The client does not have moderate hypothermia; therefore, the client does not have a body temperature of 30 C or 33 C.

The nurse would instruct a client with type I diabetes to dispose of a used syringe in which container? A. Bubble wrap/packaging wrap B. A garbage bag in the trashcan C. A cardboard box with a firmly secured lid D. A plastic liquid detergent bottle with a screw-top lid

D. A plastic liquid detergent bottle with a screw-top lid Rationale: Most states allow clients to place used needles/pen needles and lancets (sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque, sturdy plastic container with a screw-top lid. Some states do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.

Which theory is based on the model of primacy of caring? A. Roy's theory B. Watson's theory C. Neuman's theory D. Benner and Wrubel's theory

D. Benner and Wrubel's theory Rationale: The model of primacy of caring is the basis of Benner and Wrubel's theory. This theory focuses on client's need for caring as a means of coping with stressors of illness. According to Roy's theory, the goal of nursing is to help the client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity in regard to the humanistic aspects of life. This theory promotes health restoring the client to health, and preventing illness. Neuman's theory is based on stress and the client's reaction to the stressor.

Which interview technique is the nurse using when asking a client to score his or her pain on a scale from 0-10? A. Probing B. Back channeling C. Open-ended questioning D. Closed-ended questioning

D. Closed-ended questioning Rationale: Asking a client to score pain on a scale of 0 to 10 is a type of closed-ended question. These types of questions specify the cause of the problem or the client's experience of the illness. Asking whether anything else is bothering the client is an example of probing. When a client says something, a response by the nurse such as "All right" or "Go on" is called back channeling. This interview technique encourages a client to provide more details. The nurse asks open-ended, nonspecific questions such as "What brought you to the hospital today?" to elicit the client's side of the story. Such questions are related to the client's health history and can strengthen the nurse-client relationship.

After abdominal surgery, a client reports pain. Which action would the nurse take first? A. Reposition the client B. Obtain the client's vital signs. C. Administer the prescribed analgesic. D. Determine the characteristics of the pain.

D. Determine the characteristics of the pain. Rationale: The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause fo the pain.

How will the nurse researcher categorize research in which subjects are given chlorhexidine and povidone-iodine as antiseptics? A. Evaluation research B. Descriptive research C. Correlational research D. Experimental research

D. Experimental research Rationale: The nurse will categorize this study as experimental research. In experimental research, the investigator gives variables randomly to the subjects. In this case subjects are given chlorhexidine and povidone-iodine to test their efficacy in reducing infection. Evaluation research is an initial study that refines a hypothesis, such as testing a new exercise in older clients with dementia. In a descriptive study, the characteristics of a person or a situation are measured. For example, a researcher may examine nurses' bias while caring for obese clients. Correlational research is used to find out the relationship between different variables without the interference of a researcher. An example is determining the educational status of nurses and their satisfaction with their jobs.

Which feature, according to Benner, is observed in the nurse at the "proficient" level? A. Learns by means of a set of rules B. Identifies the principles of nursing care C. Identifies problems related to the health care system D. Focuses on managing care rather than managing skills

D. Focuses on managing care rather than managing skills Rationale: The nurse at the proficient level has more than 2 or 3 years of experience in the same clinical position. The nurse focuses on managing care rather than managing and performing skills. The novice nurse learns by means of a set of rules, which are usually stepwise and linear. The advanced beginner has observational experience and is able to identify the principles of nursing care. The expert nurse is skilled at identifying client-centered problems, health care system-related problems, and the needs of the novice nurse.

Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? A. Activity theory B. Continuity theory C. Disengagement theory D. Gerotranscendence theory

D. Gerotranscendence theory Rationale: The gerotranscendence theory is a recent theory that proposes the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. the continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.

An abscess develops in an obese adult after abdominal surgery. The wound is healing by secondary intention. Which diet would the nurse expect the health care provider to prescribe to meet this client's immediate nutritional needs? A. Low in fat and vitamin D B. High in calories and fiber C. Low in residue and bland D. High in protein and vitamin C

D. High in protein and vitamin C Rationale: Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.

Which step in the nursing process would involve promoting a safe environment for the client? A. Planning B. Diagnosis C. Assessment D. Implementation

D. Implementation Rationale: The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine health care issues. The nurse collects comprehensive data pertinent to the client's health and situation during the assessment stage.

Which skill in critical thinking requires the nurse to be orderly in data collection? A. Analysis B. Inference C. Evaluation D. Interpretation

D. Interpretation Rationale: Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used. When the data collected about the client helps in solving an existing problem, then the skill called inference is being used. Evaluation is used when the results of nursing actions are determined.

Which action indicates that the nurse is actively listening to the client? A. Stating personal opinions when the client is speaking B. Refraining from telling personal stories to the client C. Reading the client's health record during the conversation D. Interpreting what the client is saying and restating it for clarification

D. Interpreting what the client is saying and restating it for clarification Rationale: The nurse is listening actively if what the client says is taken in. The nurse who is listening attentively interprets and reiterates what the client is saying in his or her own words. The nurse who states personal opinions when the client is speaking is being judgmental. A good listener would be able to establish rapport by exchanging personal stories with the client. If the nurse reads the client's health record during the conversation, it is an indication that the nurse is not really interested in the conversation.

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. Which would be the type of skin lesion involved? A. Wheal B. Papule C. Vesicle D. Macule

D. Macule Rationale: A macule is a flat, nonpalpable change in skin color that is smaller than 1 cm. A wheal is a localized edema, usually caused by a mosquito bite. Wheals are irregular in shape and have elevated surfaces. Papules are palpable, circumscribed solid elevations in the skin that are smaller than 1 cm. Vesicles are small. circumscribed skin elevations that are filed with serous fluid.

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room would the nurse assign this client? A. Private room B. Semiprivate room C. Room with windows that can be opened D. Negative-airflow room

D. Negative-airflow room Rationale: Tuberculosis is an airborne contagious disease that is best contained in a negative-airflow room. Negative-airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.

The nurse concludes that a client with a body temperature of 98.6 F is experiencing which condition? A. Hypothermia B. Hyperpyrexia C. Hyperthermia D. Normothermia

D. Normothermia Rationale: A body temperature of 98.6 F is normal. The nurse concludes that the client has normothermia. The client does not have low body temperature or hypothermia. The client's body temperature does not exceed the normal range; therefore, the client does not have hyperpyrexia or hyperthermia.

Which concept refers to respecting the rights of others? A. Maturity B. Systematicity C. Inquisitiveness D. Open-mindedness

D. Open-mindedness Rationale: Open-mindedness refers to respecting the rights of others and being tolerant of different viewpoints. Maturity refers to reflecting on one's own judgements and having cognitive maturity. Systematicity refers to being organized and focused. Inquisitiveness refers to acquiring knowledge.

Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurses observe? A. Instruct the client to position one arm on each shoulder of the nurses B. Direct the client to extend the legs and remain still during the procedure C. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. D. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

D. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. Rationale: Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joins, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses would assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the bed of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction in which the client is being moved.

A client complains of pain in the ear. While examining the client, the nurse finds swelling in front of the left ear. Which lymph node would the nurse expect to be involved? A. Mastoid B. Occipital C. Submental D. Preauricular

D. Preauricular Rationale: The preauricular lymph node is located in front of the ear and in this situation would be edematous. The mastoid or posterior auricular lymph node is present behind the ear. The occipital lymph nodes are located in the back of the head, near the occipital bone of the skull. Submental lymph nodes are located below the chin.

Which is the goal of nursing according to Watson's theory? A. Helps the client attain total self-care B. Develops a positive interaction between the nurse and the client C. Works interdependently with other health care workers D. Promotes health, restores the client to health, and prevents illness

D. Promotes health, restores the client to health, and prevents illness Rationale: According to Watson's theory, the goal of nursing is to promote health, restore the client to health, and prevent illness. Watson's theory is the first theory to include the concept of caring. The goal of Orem's theory is to help a client attain total self-care. The goal of Peplau's theory is to develop a positive interaction between the nurse and the client. The goal of Henderson's theory is to work independently with other health care workers.

Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? A. Listening B. Spiritual caring C. Providing presence D. Relieving pain and suffering

D. Relieving pain and suffering Rationale: Relieving pain and suffering is not just about giving medications but includes providing comfort, dignity, respect, and peace to a client. Listening helps clients find balance between their own life values, goals, and belief systems. Providing presence helps convey closeness and a sense of caring.

The home health care nurse visits a client who lives with her two grandchildren. Which term would the nurse use to define this family form? A. Nuclear family B. Extended family C. Single-parent family D. Skip-generation family

D. Skip-generation family Rationale: A skip-generation family is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of a husband and wife and one or more children. An extended family consists of nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, or desertion. It may also occur when a single person decides to have or adopt a child.

Which theories are relevant only to development in adults? Select all that apply. A. Piaget's theory B. Erikson's theory C. Kohlberg's theory D. Stage-Crisis theory E. Life Span approach

D. Stage-Crisis theory E. Life Span approach Rationale: The Stage-Crisis theory and the Life Span approach are theories related to adult development. Piaget's theory is associated with children's cognitive development. Erikson's theory is associated with psychoanalytical development. Kohlberg's theory is related to moral development.

A community health care nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness? A. The children are underimmunized and at risk for childhood illnesses. B. The children are more likely to drop out of school and become unemployable. C. The children have access to health care only through the emergency department. D. The children do not have a physical shelter and may sleep outdoors or in vehicles.

D. The children do not have a physical shelter and may sleep outdoors or in vehicles. Rationale: Public health organizations use the term absolute homelessness to describe people who have no physical shelter. These children sleep outdoors, in vehicles, abandoned buildings, or other places not intended for human habitation. Relative homelessness describes those who have a physical shelter but one that does not meet the standards of health and safety. Children experiencing both absolute and relative homelessness tend to be underimmunized and are at risk for childhood illnesses. Both types of homeless children are unable to meet residency requirements for public schools and are more likely to drop out of school and be rendered unemployable. A lack of finances leads both types of homeless children to seek health care only in emergency conditions.

The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client? A. All nursing functions will be completed by discharge. B. All invasive intravenous lines will remain patent C. The client will remain awake, alert, and oriented at all times. D. The client will be free of signs and symptoms of infection by discharge.

D. The client will be free of signs and symptoms of infection by discharge. Rationale: Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.