Hurst 5

What action by the nurse is most helpful when responding to a bomb threat phone call? 1. Ask where and when the bomb is going to explode. 2. Quickly terminate the conversation and call in the bomb threat. 3. Document on the hospital Bomb Threat Checklist. 4. Immediately seek cover and warn others.

1. CORRECT. The nurse should keep the caller on the phone for as long as possible and try to obtain information, while being alert for voice characteristics and background noises. While keeping the caller on the line, the nurse should motion to another employee to call in the bomb threat. 2. INCORRECT. You should keep the caller on the line and signal someone to call in the threat. Keeping the caller on the line keeps them busy and may allow enough time for law enforcement to trace the call. 3. INCORRECT. It is important to document on the hospital Bomb Threat Checklist, but the most immediate action is to keep the caller on the line. 4. INCORRECT. While your initial response may be to run for cover, you should remain calm and not panic, continuing to keep the caller on the line.

The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.

1. Correct: Puerto Rican clients tend to cope with pain by loud and outspoken reports of pain. This is consistent with Puerto Rican culture and their response to pain. 2. Incorrect: Quietly enduring pain is consistent with the Japanese culture. This is consistent with the Asian culture and brings honor. 3. Incorrect: Stoic responses are consistent with Asian culture. The client is likely to be quiet about the pain thinking that complaints of pain will bring dishonor to the family. 4. Incorrect: Filipino clients tend to view pain as God's will. They may refuse medication to relieve the pain.

The charge nurse is assigning an unlicensed assistive personnel (UAP) to take vital signs on a group of adult clients. The charge nurse would instruct the UAP that a rectal temperature is contraindicated for which client? 1. Client with thrombocytopenia. 2. Client with a fractured femur. 3. Client with an inguinal hernia. 4. Client with irritable bowel syndrome.

1. Correct: Thrombocytopenia is the deficiency of platelets in the blood. Due to the reduced platelet count, the clotting time of the client's blood will be reduced. Inserting a rectal thermometer increases the client's risk of rectal trauma. If there is rectal bleeding from the insertion of the rectal thermometer, the client may experience increased bleeding due to their decreased platelet count. 2. Incorrect: A client with a fractured femur can have their temperature assessed by a rectal temperature. There are no contraindications for a rectal temperature. 3. Incorrect: To evaluate a client's temperature by inserting a rectal thermometer is acceptable procedure for a client with an inguinal hernia. 4. Incorrect: There are no contraindications for clients with irritable bowel syndrome to have their temperature assessed by a rectal thermometer.

A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the case manager to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? 1. To self-determination 2. To decline participation in research studies and experimental treatments 3. To expect reasonable continuity of care 4. To make decisions about the plan of care 5. To advocacy

1., & 4. Correct: Under the Patient Self-Determination Act (PSDA), healthcare institutions provide clients with a summary of their rights when making health care decisions as well as the facility's policies regarding recognition of advanced directives. The client is advised of the right to consent to or refuse treatment. Client rights refer to such matters as access to care, dignity, confidentiality, and consent to treatment. The competent adult client has the right to participate in the plan of care, to refuse a proposed treatment, and to accept alternative care and treatment. Documentation should be made that the client fully understands the risks and benefits of their decision. 2. Incorrect: The right to decline participation in research or experimental studies is incorrect because no research or experimental treatment is proposed to the client. 3. Incorrect: The right to expect reasonable continuity of care appears to be a possible correct answer, but is incorrect because the client has not been transferred to hospice home care. Attempting to convince the client to agree to cancer treatment would not be pertinent to continuity of care in this situation. 5. Incorrect: The right to advocacy relates to the right to have another person present during interviews or examinations. This right would not be violated by the nurse if attempts were made to convince the client to have cancer treatment.

A client has developed preeclampsia at 30 weeks' gestation. The nurse is instructing the client on an appropriate diet for preeclampsia. The nurse knows the teaching was successful when the client selects what menu? 1. Caesar salad with feta cheese 2. Grilled cheese with tomatoes 3. Chipped ham on a croissant roll 4. Hot dog with a glass of soda pop 5. Chicken sandwich on wheat toast

2 and 5. CORRECT: A high protein, calcium rich diet is most important for the preeclampsia client who is losing protein in urine. Grilled cheese is an excellent selection for lunch, especially since it contains tomato slices, which adds another level of nourishment and vitamins. Additionally, a chicken sandwich, particularly on whole wheat toast, is very appropriate for this preeclampsia client. 1. INCORRECT: Caesar dressing is made with raw eggs, exposing the client to the potential for salmonella. Pregnant woman should not eat raw foods, including eggs, fish, or meat. Additionally, feta cheese is a 'soft cheese', exposing the client to another bacterium known as listeria. Although a salad could be a good choice, this particular salad is not healthy. 3. INCORRECT: The need to restrict salt is not a priority for preeclampsia clients, but chipped ham is a processed meat containing less protein than other meats and increasing the risk for contracting listeria. The croissant roll is made of refined white flour and sugar. The client would benefit more from whole grain products. 4. INCORRECT: Processed meats, such as hot dogs, are not the healthiest choice for the client, as they increase the risk for listeria. Also, a client with preeclampsia should avoid alcohol, caffeine, and refined sugar to help control the blood pressure. The glass of soda pop is not a healthy selection.

A home health nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."

2. Correct: For intermittent catheterization in the home, the client should follow clean technique. Wash rubber catheters thoroughly with soap and water after use, then dry and store in a clean place. 1. Incorrect: There is no drainage bag for intermittent catheterization. If there was an indwelling catheter, it would be secured to the woman's upper thigh. 3. Incorrect: With intermittent catheterization, there is no drainage bag. This would be an incorrect comment if made by the client. 4. Incorrect: Intermittent catheterization should be done first thing in the morning and just before going to bed at night. In most cases, self catheterization should be done every 4 to 6 hours. The client may need to self catheterize more frequently if oral intake of fluids has increased.

The charge nurse is observing a nurse perform a dressing change on a client with a Stage III pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigates the pressure ulcer with 50 mL normal saline. 2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. 3. Packs the wound with sterile gauze soaked in normal saline. 4. Applies a hydrocolloid dressing over the wound after cleansing.

2. Correct: Pressure ulcers should not be cleaned with substances that are cytotoxic such as hydrogen peroxide, betadine or Dakin's solution. Cytotoxic means toxic to cells, or cell-killing. Any agent or process that kills cells. These solutions can kill or damage cells, especially fibroblasts. Dakin's solution is a type of hydrochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine is the active ingredient in Dakin's solution. 1. Incorrect: Normal saline is an appropriate solution and is used to clean pressure ulcers. This does not kill or damage cells. 3. Incorrect: Normal saline is an appropriate solution and pressure ulcers may be packed with sterile gauze. This helps remove necrotic tissue. 4. Incorrect: The wound should be covered with an appropriate dressing after cleaning. Hydrocolloid dressings support healing in clean granulating wounds and autolytically debride necrotic wounds. Hydrocolloid dressings are occlusive, so they provide a moist healing environment, autolytic debridement, and insulation.

The nurse provides instructions on the proper use of crutches to a client. Which comment by the client indicates a need for additional instructions? 1. "I move the crutches 6 to 12 inches ahead prior to moving foot forward." 2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg." 3. "When rising from a chair, I will place crutches on my affected side, lean forward, and push off from the chair with one hand." 4. "To climb stairs I will advance my unaffected leg past crutches, then place weight on unaffected leg, and advance affected leg and the crutches to the step."

2. Correct: This client will need additional instruction. The client should place their crutches on the step below first. Then move the affected leg down to the next step. The client should follow with the unaffected leg. 1. Incorrect: This is a correct statement by the client. The crutches are to be moved 6 to 12 inches forward and then the client steps past the crutches. 3. Incorrect: The client is describing the correct steps in rising from a chair. Both crutches are placed in one hand. The client should then push off from the chair with one hand. 4. Incorrect: The client should advance their unaffected leg up to the next step and place their weight on unaffected leg. Then the affected leg and the crutches should be advanced to the next step.

Which response by the nurse is appropriate when responding to a client who reports eliminating all dairy foods from their diet because of lactose intolerance? 1. "Take calcium tablets since they can be used as a total supplement for dairy products." 2. "You can take lactose enzymes which will eliminate the effects of lactose intolerance." 3. "Valuable nutrients found in milk include calcium and protein." 4. "Consume more leafy green vegetables to maintain calcium levels."

3. Correct: Milk contains both calcium and high-quality protein. 1. Incorrect: Dairy products provide for both calcium and protein. 2. Incorrect: Lactose enzymes may help but will not eliminate the problem. 4. Incorrect: People generally do not eat enough green leafy vegetables to get enough protein.

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first? 1. Convince the client to proceed with the plans for surgery. 2. Notify the surgery department to cancel surgery. 3. Notify the primary healthcare provider of the client's decision. 4. Suggest that the client talk over the decision with family members.

3. Correct: The client has the right to make decisions about their care. The primary healthcare provider should be notified about the client's decision to not have the surgery. 1. Incorrect: The nurse should not try to convince the client into having the surgery. If the nurse tries to have the client do something they do not want to do, the client is being coerced to make a decision by the nurse. This breaches the client's rights. 2. Incorrect: The primary healthcare provider should be notified prior to the surgery department being notified. The primary healthcare provider will need to review the client's plan of care with the client. 4. Incorrect: The client has informed the nurse of their decision. The nurse should not suggest any further action related to the client's decision. The client has the right to make decisions autonomously.

A nurse is feeding a client diagnosed with a stroke who is exhibiting dysphagia. Which action by the nurse would be appropriate? 1. Elevate the head of the bed to 15 degrees. 2. Request the client to not hold food in their mouth. 3. Monitor for frequent throat clearing after eating. 4. Orient the client to the location of food on their plate.

3. Correct: When helping to feed a client with dysphagia, the nurse should monitor for signs of aspiration such as frequent throat clearing during and after meals. The client is trying to move the bolus of food down esophagus. Aspiration is a condition where food, liquids or saliva moves into the lungs instead of the esophagus during eating. 1. Incorrect: The client should be sitting upright or a high-fowlers position. This position allows for more flexibility of neck movement to promote swallowing. The nurse can keep the client's neck in the neutral position or their chin lowered to their chest. 2. Incorrect: Why is the client holding food in their mouth? Are they disoriented or with a cognitive impairment? Asking a client who is disoriented or with a cognitive impairment to not hold food in their mouth is not an effective intervention. 4. Incorrect: Does the location of the food on the plate affect how a client swallows the food. The location of the food will not affect the possibility of the client aspirating during swallowing food.

The nurse asks if the client has an advance directive. The client responds by saying, "What is an advance directive?" What is the nurse's best response to the client's question? 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. Specifies your wishes regarding healthcare and treatment options should you become incapacitated. 5. The person signing the advanced directive must be competent.

4. & 5. Correct: An advance directive is a legal document prepared by a competent individual that specifies what treatments, if any, the client desires should the client become incapacitated or unable to make informed healthcare decisions in the future. The person signing the advance directive must be able to understand and agree with the document. 1. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament but are not part of an advance directive. 2. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament but are not part of an advance directive. 3. Incorrect: An advance directive does not address burial wishes.

At a summer pool party, an adult client is found unconscious in the water. Someone calls 911, and a nurse present at the party immediately initiates what priority action? 1. Initiate chest compressions. 2. Assess client for any injuries. 3. Wrap client in warm blankets. 4. Check for any respirations.

4. CORRECT: In any emergency situation, the nurse must still adhere to Maslow hierarchy and follow current American Heart Association guidelines when assessing a client. Once the client has been pulled from the water, the first action is to open the airway and check for the presence of spontaneous respirations. 1. INCORRECT: While this client will most likely require cardiopulmonary resuscitation, the nursing process requires assessment prior to initiating any action. Additionally, checking for any respirations must be done before starting chest compressions. 2. INCORRECT: There is no information on whether the client fell into the pool or was already in the pool; therefore, the client will need to be assessed for injuries at some point. However, that particular assessment is not the initial priority action. 3. INCORRECT: The client's core body temperature may be decreased. However, hypothermia is not an initial concern with this client, and in fact, hypothermia can sometimes be beneficial in a drowning situation.

How does the nurse identify the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.

4. Correct: Measuring the client from 2 inches below the axilla to 6 inches lateral to the client's heel correctly measures a client for crutches. This is the correct size while a client is standing. 1. Incorrect: This is not the correct way to choose the correct size crutches. Without the proper fit safety is a concern. 2. Incorrect: This is not how to choose the correct size of crutches. The client should not rest their weight on the crutch pad as this can cause damage to the brachial plexus nerve. 3. Incorrect: This is not how to choose the correct size of crutches. The shoulders should be relaxed, the hand piece should be adjusted to provide a 20°- 30° elbow flexion. The 2 inch drop below the axilla allows the weight to be pressed against the sides and the hands absorb the weight. The crutch should not be placed against the axilla or the brachial plexus nerve could be damaged.

Preparing to administer a bolus enteral feeding to a client who is receiving a proton pump inhibitor, a nurse checks the pH of aspirated gastric fluid to determine feeding tube placement. The pH reading is 6. Which action should the nurse take next? 1. Initiate the tube feeding. 2. Replace the feeding tube. 3. Notify the primary healthcare provider of the assessment finding. 4. Inspect the aspirated contents for color and consistency.

4. Correct: The nurse should inspect the aspirated stomach contents for color and consistency to determine correct feeding tube placement. The normal stomach pH value is 1 to 4; however, when a client is receiving medications to decrease stomach acidity, the pH of the gastric aspirate may be as high as 6 and similar to the pH of respiratory secretions. Small intestines aspirates can also have a pH equal to or higher than 6. A pH of 6 does not confirm correct tube placement. Gastric contents are cloudy, green, tan, or off white, bloody or brown. 1. Incorrect: The tube feeding should not be initiated until feeding tube placement has been confirmed. 2. Incorrect: It is not necessary to replace the feeding tube at this time. Look at the aspirated contents for color and consistency. 3. Incorrect: Further data should be collected before notifying a primary healthcare provider.

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take? 1. Consult with the primary healthcare provider. 2. Assess the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

2. & 5. Correct: The nurse should carefully assess the client. The nurse must serve as an advocate for the client. A pain scale is used to determine level of pain. 1. Incorrect: The nurse must assess the client before consulting with the primary healthcare provider about the medication. 3. Incorrect: This action assumes that the client does not have pain, which does not take into consideration what is wrong with the client. 4. Incorrect: This action assumes that the client is a "drug seeker". The nurse must carefully assess the client.

A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

2. Correct: Continuous bladder irrigation is used following surgery to ensure that the bladder remains clear of blood clots.The nurse would need to increase the irrigation rate until the urine becomes light pink. 1. Incorrect: If the urine is not diluted, the client could form clots in the urine that could obstruct the urine flow. Charting the drainage color and amount would not address the issue. 3. Incorrect: Dark red color to the urine would warrant an increase in irrigation. There is no need to call the primary healthcare provider. If the color of urine doesn't clear or the vital sign show signs of shock (increased heart rate and decreased blood pressure) then notifying the primary healthcare provider would be needed. 4. Incorrect: This is the intervention that would be carried out if the client is hemorrhaging from the prostate. The balloon on the catheter would be used to apply pressure to the prostate and decrease bleeding. If there was more evidence of hemorrhage such as a decrease in blood pressure or increase in heart rate this type traction would be initiated. There is not enough evidence of hemorrhage at this point to initiate traction, therefore, more assessments should be performed.

Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? 1. Nonmaleficence 2. Beneficence 3. Justice 4. Fidelity

1. Correct: Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented. 2. Incorrect: Beneficence refers to doing good. This may include compassion and kindness. 3. Incorrect: Justice refers to equitable distribution of resources. Triage in the ED is one action that illustrates justice. 4. Incorrect: Fidelity refers to truth-telling. If the client were to ask if a medication error was made, the nurse would answer yes to the question as a way of demonstrating fidelity.

The charge nurse is evaluating a newly hired LPN/VN graduate. Before assigning a client to be prepped for a colonoscopy, the nurse asks the LPN/VN to verbalize the correct steps for completing an enema. In what order should the LPN/VN verbalize the steps for an enema? The Correct Order Explain procedure to the client. Assist client to a side lying position. Add warm water to the enema bag. Raise enema bag 18" to 20". Insert lubricated tip into rectum.

All procedures should be explained to the client first, allowing time for the client to ask questions or express any concerns. Second, positioning the client comfortably with attention to privacy is important for both comfort and ease of completing procedure without complications. Positioning should be done so that the water remains warm during the procedure. Third, the water must be warm enough to prevent cramping and discomfort during the procedure; once the enema bag is filled, it should be hung next to the bed for use. Fourth, raising the enema bag allows gravity to assist with the flow of fluid from the bag into the client. Fifth, the tip of the nozzle must be completely lubricated to prevent friction or trauma to the rectal tissue. The tip is gently inserted into the rectum, aiming the tip of the nozzle towards the umbilicus when inserted. (If the client begins to experience cramping, the first action is to lower the bag and stop the flow.)

After applying sterile gloves, what process should the nurse use to remove interrupted sutures from a client's surgical wound? Place in the correct order. The Correct Order Moisten dried crust with sterile 0.9% sodium chloride solution. Clean suture line with antimicrobial solution. Gently grasp the knot with forceps and raise it slightly. Place the curved tip of suture scissors directly under the knot. Gently cut the suture. Pull suture out with forceps. Make certain all suture material is removed. Put suture on clean gauze. Apply sterile wound strips. Document date, time, and number of sutures removed.

First, Moisten dried crust with sterile 0.9% sodium chloride solution. Second, clean suture line with antimicrobial solution. Third, gently grasp the knot with forceps and raise it slightly. Fourth, place the curved tip of suture scissors directly under the knot. Fifth, gently cut the suture. Sixth, pull suture out with forceps. Seventh, make certain all suture material is removed. Eighth, put suture on clean gauze. Ninth, apply sterile wound strips. Tenth, document date, time, and number of sutures removed.