Practice questions

The nurse is providing staff education on reducing hospital acquired infections by eliminating potential reservoirs of infection. Which of the following statements should be included in the teaching? A) "Client bedrails should be disinfected regularly using hospital approved wipes." B) "It is a good idea to wear gloves when touching door handles." C) "Documentation areas are cleaned less often than client rooms." D) "Soiled linens should remain in the client's laundry bin until discharge."

A) "Client bedrails should be disinfected regularly using hospital approved wipes." Rationale: Research has shown that one of the biggest reservoirs of infection is the client's bedrails. These must be thoroughly sterilized between patients. Gloves are a potential source of infection. If someone is wearing gloves and touches a reservoir then touches the door handle, the door handle becomes a reservoir. Clients, visitors, healthcare providers, and facility staff may touch door handles multiple times each day. Office supplies, computer mice, and keyboards are all potential sources of infection and need to be diligently cleaned. Linen bags should be brought directly to the soiled utility room.

A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive personal (UAP) who will assist the client to ambulate? A) "Have the client lift and move the walker out to arm's length, then walk into the walker." B) "As you assist the client to the chair, let me know if the client uses the quad cane correctly." C) "Stand on the client's strong side when you assist the client to the bathroom." D) "If the client becomes dizzy while walking, ask the client to stop and take 10 fast, deep breaths."

A) "Have the client lift and move the walker out to arm's length, then walk into the walker." Rationale: The nurse should give clear and concise information to the UAP about what is expected to safely complete any task, which is why the option about using the walker is correct. The person assisting the client to ambulate should walk on the client's weak, not strong, side. The nurse should not instruct the UAP to assess or evaluate a client (e.g., "let me know if the client uses the quad cane correctly"). Only nurses can perform those steps of the nursing process. If the client feels dizzy, the UAP should assist them to sit (or ease the client to the floor if they begin to fall.)

The home health nurse is visiting with an older adult client who recently moved in with their adult child. Which statement by the client would indicate to the nurse the client might be experiencing mistreatment? A) "I recently added my daughter on to my bank account." B) "I had an appointment to replace my eyeglasses." C) "I have joined a church group that meets during the day." D) "I try to help my daughter with preparing meals."

A) "I recently added my daughter on to my bank account." Rationale: Older adults are at risk for mistreatment, which is the intentional acts or lack of care by a caregiver towards the client. Mistreatment can be neglect, which would be failure to provide social interactions, and providing basic food, water, and physical aids, such as eyeglasses. Financial abuse refers to the denying the client access their personal resources, stealing money, or coercing the client to sign contracts.

A nurse is evaluating a client who was prescribed chlorpromazine for schizophrenia 1 week ago. The client tells the nurse "I feel better but I still experience hallucinations often. I don't think the medication is working." How does the nurse respond to the client's concern? A) "It can take several weeks for the medication to produce full therapeutic effects." B) "It is very difficult to manage your condition." C) "I will notify the healthcare provider to switch your medication regimen." D) "Tell me what kind of hallucinations you are having."

A) "It can take several weeks for the medication to produce full therapeutic effects." Rationale: Antipsychotics such as chlorpromazine may take 7 to 8 weeks, or longer, to produce noticeable therapeutic effects. The nurse should emphasize the timeline to the client to ensure medication compliance. Stating it is difficult to manage the client's condition does not address the client's concern or emphasize expected therapeutic timelines. The medication regimen does not need to be revised. Therapeutic effects may not be seen until several weeks. Assessing the client's hallucinations is important. However, this does not address the client's concern regarding the medication.

The charge nurse observes a staff nurse carrying soiled linen in the hallway from a client who is receiving chemotherapy. Which statement by the charge nurse would be most appropriate? A) "Soiled linens should be held away from the body and placed in a linen cart or bag before leaving the room." B) "Soiled linens should be left in the client's room to prevent the spread of biohazardous and infectious materials." C) "Linens should be changed weekly to prevent exposure to cytotoxic agents." D) "Linens should be held closely to reduce the risk of any biohazardous or infectious materials from becoming airborne."

A) "Soiled linens should be held away from the body and placed in a linen cart or bag before leaving the room." Rationale: Blood and body fluids are contaminated with cytotoxic drugs or metabolites for about 3 to 5 days after a dose. Therefore, the nurse should wear appropriate PPE when handling patients' clothing, bed linens, or excreta. Linens should be placed in a specially labeled linen cart or plastic bag before being taken to the soiled utility room. It is important that meticulous hygiene is administered to the patient undergoing chemotherapy to help prevent infection. Therefore, linens should be changed as needed. Linens should be held away from the body to prevent contamination of the nurse's clothing.

The nurse is assigned to care for four clients in the emergency department. Which client should the nurse see first? A) A 34-year-old with a tension pneumothorax and tracheal deviation B) A 59-year-old with suspected viral pneumonia and atelectasis C) A 45-year-old with spontaneous pneumothorax and a respiratory rate of 28 D) A 22-year-old with acute asthma with episodes of bronchospasms

A) A 34-year-old with a tension pneumothorax and tracheal deviation Rationale: Tension pneumothorax occurs when there is an accumulation of air under pressure in the pleural space. This causes compression of the lungs and decreases venous return to the heart. Tracheal deviation indicates a significant volume of air is trapped in the chest cavity, causing a mediastinal shift. This is a medical emergency. In tension pneumothorax, the tracheal deviation is away from the affected side. This situation also results in sudden air hunger, agitation, hypotension, pain in the affected side and cyanosis with a high risk of cardiac tamponade and cardiac arrest. This patient is the most critical and should be seen first.

The charge nurse is required to recommend a client that can be discharged in the next hour due to a disaster plan activation. The nurse should recommend which client for discharge? A) A client post-laparoscopic cholecystectomy with a prescription for a soft diet B) A client with a comminuted pelvic fracture who is taking oral analgesics C) A client with atelectasis on oxygen via nasal cannula D) A client with a foot ulcer who is receiving intravenous antibiotics

A) A client post-laparoscopic cholecystectomy with a prescription for a soft diet Rationale: A postoperative client who is tolerating oral intake is considered stable for discharge. A laparoscopic cholecystectomy is minimally invasive, and clients are usually discharged within a day. A client with a comminuted pelvic fracture cannot be mobilized until treated. A client with atelectasis who requires oxygen therapy is not stable for discharge within an hour. A client receiving intravenous antibiotics is not ready for discharge. Intravenous therapy requires care management collaboration prior to discharge.

The nurse is providing care for an elderly Mexican-American migrant worker after an accident. To facilitate communication the nurse should initially take which of these actions? A) Evaluate the client's ability to speak English. B) Request a Spanish interpreter. C) Speak to the client through the family or coworkers. D) Use pictures, letter boards or hand gestures.

A) Evaluate the client's ability to speak English. Despite the cultural heritage, a nurse cannot make assumptions that the client does not understand nor speak English. Stereotyping is to be avoided. The nurse should evaluate if the client is comfortable with and has an ability to understand or speak English. Until the nurse determines the client's ability to speak and understand English, an interpreter of any type is not needed nor is it necessary to use other means of communication.

A nurse is setting up the sterile field for an indwelling catheter insertion. As the nurse applies the sterile gloves, the client verbalizes they forgot to mention a past allergy to latex. Which action does the nurse take? A) Instructs the client to use the call bell to call another nurse. B) Informs the client the procedure is brief so exposure will be minimal. C) Discards all of the equipment and obtains a new catheter kit. D) Removes the sterile gloves to apply latex-free clean gloves.

A) Instructs the client to use the call bell to call another nurse. Rationale: The client is able to assist the nurse by using the call bell to call another nurse. The nurse can request a different set of sterile gloves from the other nurse to avoid contaminating the sterile field or discarding the equipment. Every allergy should be considered significant. The nurse must eliminate any chance of exposure. Discarding the entire kit is not necessary. The nurse can request another nurse to obtain alternative sterile gloves and still maintain a sterile field. The procedure requires sterile technique. Clean gloves can increase the risk of contamination and infection.

A nurse reviews a prescription to discontinue a nontunneled central venous access device. Which action will the nurse perform to prevent an air embolism? A) Position the client supine before catheter removal B) Cleanse the insertion site with CHG solution prior to catheter removal C) Instruct the client to take deep breaths during catheter removal D) Apply pressure to insertion site after catheter removal

A) Position the client supine before catheter removal Rationale: An air embolism is a potential complication of central venous access device removal. Positioning the client supine promotes venous filling and prevents the formation of an air embolus. Cleansing the insertion site with chlorhexidine gluconate (CHG) decreases the risk of infection but does not specifically prevent an air embolism. Instructing the client to take deep breaths during the removal increases the risk of an air embolism. The client should be instructed to bear down (Valsalva maneuver) during removal. Applying pressure to the insertion site after removal prevents hematoma formation and reduces the risk of bleeding.

A nurse is preparing to administer procainamide to a client who takes propranolol for hypertension. Which clinical finding indicates an interaction between these medications? A) Prolonged PR interval on the electrocardiogram B) Blood pressure of 95/50 mmHg C) Butterfly-shaped rash on the client's face D) Platelet count of 100,000/mm³

A) Prolonged PR interval on the electrocardiogram Rationale: A prolonged PR interval on the electrocardiogram indicates procainamide toxicity. Beta blockers, such as propranolol, increase the risk of procainamide toxicity. A blood pressure of 95/50 mmHg is on the lower side of normal. The nurse should continue to monitor the blood pressure as procainamide and propranolol can have additive hypotensive effects. A butterfly-shaped rash is indicative of systemic lupus syndrome, a complication of procainamide. However, this complication is not due to an interaction between procainamide and propranolol. A platelet count of 100,000/mm³ is indicative of thrombocytopenia, a possible complication of procainamide that usually resolves within a month after initiation of therapy.

The nurse is caring for clients in an inpatient mental health unit. In order to develop a therapeutic milieu, the nurse should include which intervention in the client's plan of care? A) Provide a testing ground for new patterns of behavior while clients take responsibility for their own actions B) Discourage expressions of anger to avoid disrupting other clients. C) Form a group forum in which clients decide on unit rules, regulations and policies D) Offer a businesslike atmosphere where clients can work on individual goals

A) Provide a testing ground for new patterns of behavior while clients take responsibility for their own actions A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior while holding client's responsible for their actions. The other approaches are part of various types of therapy.

During a lunch break, nurse colleagues discuss their nursing practice. Which of the following statements best represents nursing practice guidelines? A) Specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs) will vary from state to state. B) The healthcare agency is ultimately responsible for developing practice guidelines for licensed nurses. C) The federal government ensures the safety of clients by developing nursing practice guidelines. D) National nursing associations are responsible for developing specific regulations for licensed registered nurses (RNs) and licensed practice nurses (LPNs).

A) Specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs) will vary from state to state. Rationale: Nursing guidelines and regulations are developed to protect those who are receiving care. It is the state's duty to ensure licensed nurses provide safe, competent nursing care. Boards of nursing are state governmental agencies that are responsible for licensing nurses in each state and enforcing the rules and regulations of the nurse practice act. Nursing scope of practice may vary from state to state. It is the responsibility of the licensed nurse to be aware of their state's scope of practice. The other statements are not true in regards to nursing practice guidelines.

A nurse is assessing a client with cholecystitis. Upon assessment, the client rates the degree of pain a 0/10. Which behavioral response indicates to the nurse that the client may require pain medication? A) The client changes position frequently B) The client is diaphoretic C) The client's blood pressure is 145/90 mmHg D) The client's heart rate is 110 beats/min

A) The client changes position frequently Rationale: Behavioral responses to pain include changes in posture and/or gross motor activities. Although the client rated their pain a 0/10, the nurse identifies frequent position changes as a possible indicator of pain and should re-assess the client. Diaphoresis, hypertension, and tachycardia are physiological, not behavioral, responses to pain.

The nurse is performing the Weber assessment test on a client who reports hearing loss in the left ear. Which finding would indicate to the nurse the client is experiencing conductive hearing loss? A) The client hears the sound vibrate from the top of the head in the affected ear. B) The client hears the sound by air conduction longer than feeling bone conduction. C) The client feels the bone conduction longer than hearing the sound conduction. D) The client pushes on the tragus while repeating back what is whispered.

A) The client hears the sound vibrate from the top of the head in the affected ear. Rationale: For the Weber test, the tuning fork is placed on the bridge of the forehead, nose, or teeth. In a normal test, the sound is heard equally in both ears. With unilateral conductive loss, sound is heard in the affected ear. With unilateral sensorineural loss, sound is heard in the normal or better-hearing side. In a Rinne test, the tuning fork is placed on the mastoid bone behind the ear until the client can no longer feel the vibration. The fork is then moved beside the ear. In a normal test, air conduction is greater than bone conduction. The whisper test has the client repeat what is heard while pushing on the tragus.

A nurse is planning care for a client post-lower extremity surgery. The client has a prescription for non-weight bearing to the right lower extremity with the use of crutches. Which client action indicates correct use of the assistive device? A) The client holds both crutches in one hand while grasping the arm of the chair with the other hand when standing. B) The client supports their body weight on the hand grips with the elbows flexed to 15 degrees. C) The client places the crutches 12 inches in front and to the side of each foot. D) The client bends their back forward over the crutches when ambulating.

A) The client holds both crutches in one hand while grasping the arm of the chair with the other hand when standing. Rationale: Holding both crutches on one hand and grasping the arm of the chair with the other hand is proper body mechanics and use of crutches. This action provides balance when shifting from a sitting position to standing. The elbows should be flexed at 20 to 30 degrees to maintain proper upper body alignment. Placing the crutches 12 inches in front and to the side of each foot does not provide a strong base of support. The crutches should be placed approximately 6 inches in front and to the side of each foot. The client should be instructed to stand up straight to maintain proper body alignment while ambulating with crutches.

The nurse manager on a medical surgical unit is assigning care to a nurse who floated from the labor and delivery unit. Which client would be best to assign to the labor and delivery nurse? A) The client who had an appendectomy and has prescription for ambulation. B) The client who had a right below the knee amputation and has a surgical drain in place. C)The client with a gastrointestinal bleed and has a prescription for blood transfusion. D) The client with a pressure injury and requires wound care.

A) The client who had an appendectomy and has prescription for ambulation. Rationale: When assigning care to a client who has floated from another unit, the nurse manager should assign clients based on the nurse's level of experience. A labor and delivery nurse would have experience caring for clients following a cesarean section, which is an abdominal surgery, so the client who had appendectomy would be appropriate. A client with a gastrointestinal bleed, BKA, and pressure injury require a nurse with experience with that level of care.

An American Indian tribal leader visits his newborn son at the hospital and performs a traditional ceremony that involves feathers and chanting or singing. Which action by the nurse is an example of cultural competence? A) The nurse silently reflects about their own biases regarding American Indians and how they can influence how to approach the client's parent. B) The nurse begins a discussion with the client's parent by asking, "Can you tell me about other traditions that your tribe uses." C) The nurse discussed the situation with a fellow nurse and decides to contact social services to perform a home evaluation before the newborn is discharged. D) The nurse notifies the nursing supervisor to request that the parent stop chanting or singing because of noise concerns for other clients.

A) The nurse silently reflects about their own biases regarding American Indians and how they can influence how to approach the client's parent. Providing culturally competent care begins with an in-depth self-examination of one's own background and recognition of one's biases, prejudices and assumptions about other people. American Indian/Alaska Natives encompass diverse tribal groups with differing practices, traditions and ceremonies. Tribal traditions may vary, but similarities across traditions include the use of sweating and purging, herbal remedies and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people and promote wholeness and healing.

The nursing supervisor is working in an acute care facility following an earthquake. The building has lost water supply and is on generator power. Which patients should the nursing supervisor evacuate first? A) Ventilator dependent adults in the ICU B) Ambulatory adults on the medical unit C) Ambulatory children in the pediatric unit D) Non-ventilator dependent adults in the ICU

A) Ventilator dependent adults in the ICU Rationale: Evacuation decisions after No Advanced Warning Events such as earthquakes are based on building integrity, infrastructure, and environmental factors. If there is a potential or immediate threat to staff or clients, an assessment must be made to immediately evacuate or wait and reassess. Once evacuation is determined, triage is based on the availability of critical resources. In this case, the loss of power and water makes movement of acutely ill clients the priority. The other clients may be evacuated subsequently.

A nurse is assessing the daily intake and output for a client. The nurse notes that the client's total fluid intake was 2,000 mL and the client's output was 1,300 mL of urine. Which action should the nurse take? A) document the findings B) notify the healthcare provider C) advise the client to increase oral fluid intake D) perform a straight urinary catheterization

A) document the findings Rationale: The client's fluid balance is expected. The excretion of urine makes up approximately half of the daily fluid output. The rest of the fluid loss is via the skin, lungs, and gastrointestinal system. The healthcare provider should be notified when there is a significant imbalance of intake and output. Additional assessments are required to determine an imbalance. Increasing oral fluid intake is not indicated for this client. The urinary output is normal. Urinary catheterization is not indicated. The client is not showing signs of urinary retention.

A nurse is reviewing new prescriptions for a client. The nurse notes hydrochlorothiazide on the medication list. The nurse identifies which client condition as a contraindication to this medication? A) end stage renal disease B) primary hypertension C) fluid volume overload D) heart failure

A) end stage renal disease Rationale: Hydrochlorothiazide is administered to clients to promote diuresis if kidney function is not impaired. A client in end stage renal disease will not produce an adequate amount of urine and should be considered a contraindication to the administration of this medication. Hydrochlorothiazide's primary indication is the management of mild to moderate hypertension. Thiazide diuretics increase the excretion of sodium and water and are intended for clients with fluid volume overload. Heart failure leads to fluid volume overload, an indication for the administration of hydrochlorothiazide.

A client with chronic pain asks the nurse, "What is your opinion about acupuncture to help with chronic pain?" The nurse responds, "I think some of those complementary treatments can be scary." The nurse's response is an example of what perspective? A) ethnocentrism B) discrimination C) prejudice D) cultural insensitivity

A) ethnocentrism Ethnocentrism is the universal unconscious tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper and natural ways. It can be a major barrier to the provision of culturally conscious care. Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one's own are strange, bizarre or unenlightened, and therefore wrong. At a more complex level, ethnocentric people regard others as inferior or immoral and believe their own ideas are intrinsically good, right, necessary, and desirable, while remaining unaware of their own value judgments.

The infection control nurse is evaluating a staff member putting on personal protective equipment (PPE) before entering the room of a client who is on droplet isolation. Which item should the staff member put on first? A) gown B) mask C) gloves D) face shield

A) gown Rationale: When putting on PPE, the first item to put on is the gown, followed by the mask, face shield, and then gloves.

A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan? A) keep a time log for what was done during the hours worked B) complete each task before beginning another activity C) set daily goals with the establishment of priorities D) ask for additional assistance when necessary to complete tasks

A) keep a time log for what was done during the hours worked Rationale: The first step in planning for time management is to establish what tasks were done and when they were completed. This provides a baseline for needed changes in any activities and time use log. The key words in this question are "time management," "most effective," and "initial development." Remember the first step in the nursing process is data collection - this applies to both caring for clients and developing management skills.

The nurse is caring for a client with Marfan's syndrome who is preoperative for thoracic aortic aneurysm repair. Which manifestation reported by the client would require emergent intervention by the nurse? A) pain in the middle of the back B) shortness of breath C) fatigue D) nausea

A) pain in the middle of the back Rationale: A client with a thoracic aneurysm can develop a tear or rupture of the aneurysm, which is a medical emergency. Pain in the middle of the back is the hallmark manifestation of thoracic aneurysm tear. Fatigue and shortness of breath are expected findings with a thoracic aneurysm. Nausea is manifestation of myocardial infarction.

A nurse is performing a skin assessment on a client. Upon assessment, the nurse notes a bluish, papular lesion on the lip that blanches with pressure. How does the nurse document this finding? A) venous lake B) nevus flammeus C) star angioma D) actinic keratosis

A) venous lake Rationale: Venous Lake is a common vascular, benign lesion that is papular, purple or bluish in color, and blanches on pressure. These lesions are commonly found on the lips and ears. Nevus Flammeus is commonly known as a Port-Wine Stain, which is a malformation of superficial dermal blood vessels. A Star Angioma is a vascular lesion that has multiple extensions, forming a star or spider appearance. Actinic Keratosis are rough, scaly lesions that result from UV damage to the skin.

The nurse is planning care for a client with newly diagnosed pernicious anemia. Which intervention should the nurse anticipate for this client? A) vitamin b12 injection B) oral iron supplements C) transfusion of packer red blood cells D) dietary consult

A) vitamin b12 injection Rationale: Pernicious anemia is a cobalamin (vitamin b12) deficiency caused by a lack of intrinsic factor. Intrinsic factor, which is secreted by the gastric mucosa, is required to absorb vitamin B12. When a client lacks intrinsic factor, the client will have a vitamin B12 deficiency, which is treated with vitamin B12 injections. Oral iron supplements are used to treat iron deficiency anemia. A dietary consult would be an intervention for a client with folic acid anemia. A client with anemia due to blood loss will require a transfusion of packed red blood cells.

The nurse is caring for a client diagnosed with substance use disorder. What behaviors are consistent with this diagnosis? Select all that apply A) inability to abstain from a substance B) denial that the substance is a problem C) motivation to change problem behavior D) insecurity about others' feelings towards them E) experience of amnesia during substance use

A, B. D, E Substance use disorder (SUD) is a chronic illness and distinguished by a person's persistent use of a substance. Individuals with this disorder find it difficult to abstain from using the substance. Despite the consequences of using the substance, the individual is not internally motivated to change, and may not be able to identify the behavior as a problem. They often are insecure and have problems with relationships (family, friends, and work). They may experience amnesia ("blacking out") related to substance use.

The nurse is caring for a client with an ischemic stroke confirmed by CT scan. Which criteria would indicate the client is a candidate to receive tissue plasminogen activator (tPA)? Select all that apply. One, some, or all responses may be correct. A) client denies a history of gastrointestinal bleeding B) client's blood pressure is 148/88 mm/Hg C) platelet count of 200,000/mm3 D) one hour since the onset of symptoms E) client had an open cholecystectomy 8 days ago

A,B,C,D Rationale: For clients with an ischemic stroke confirmed with a CT scan, the priority treatment option is tPA, which will produce localized fibrinolysis at the site of the blockage. Because tPA can also increase the risk for bleeding, the client must meet specific criteria, including a systolic blood pressure less than 185 mm/Hg, no history of GI bleeding or head trauma in the past three months, and no surgery within the past 14 days. The client will have lab testing to assess for any coagulation issues. A platelet count of 200, 000 mm3 is normal. To be effective, tPA must be administered with 3 to 4 hours of onset of symptoms.

Which actions by the nurse would be considered a violation of the Health Insurance Portability and Accountability Act (HIPAA)? Select all that apply. One, some, or all responses may be correct. A) The nurse leaves the door of the room open while assisting a client with hygiene care. B) The nurse forces an alert and oriented client back into bed. C) The nurse administers the wrong dose of prescribed medication to a client. D) The nurse uses a client's medical record as a sample for teaching that has client identifiers listed. E) The nurse reports the condition of a client to the physical therapist.

A,B,D,E Rationale: HIPAA is the federal act that protects a client's right to privacy of their healthcare information and records. Leaving the door to the room during hygiene care is a violation of privacy. HIPAA protects clients from unnecessary use of physical restraints, such as forcing an alert and oriented client back into bed. The nurse would need to the client's consent to disclose information to an employer. Using a client's medical record with identifiers is a violation of HIPAA. Administering the wrong medication would be a medical error.

The nurse is planning care for a client who is postoperative vaginal surgery to repair a cystocele. Which interventions should the nurse include in the plan of care for this client? Select all that apply. One, some, or all responses may be correct. A) high fiber diet B) stool softener C) cleansing douche daily D) apply ice pack to perineal area E) sitz baths twice a day

A,B,D,E Rationale: When planning care for a client who had vaginal surgery, the nurse will implement interventions to prevent wound infection and pressure on the vaginal suture line. The client should have a high fiber diet and stool softener to prevent constipation, which decreases straining on the suture line. The client should perform sitz baths to cleanse the perineal area twice a day, with perineal care after the client urinates or defecates. Ice packs applied to the perineal area decreases swelling and pressure on suture line. A cleansing douche is a preoperative intervention.

A nurse is making the decision to accept the staffing assignment while floating to another unit. Which statement would be appropriate for the nurse to make? A) "How many clients will I be providing care on the assignment?" B) "Can I have a description of the characteristics of each client?" C) "Who is in charge of the staff during the shift?" D) "Will I be able to access the appropriate equipment?"

B) "Can I have a description of the characteristics of each client?" Rationale: When making the decision to accept a staff assignment, the nurse should find out what the assignment is, the characteristics of the clients, the level of experience needed to care for the clients, who will serve as the resource to the nurse, and location of the assignment. Asking how many clients assigned does not provide an adequate picture of the assignment. Who is in charge is not the same as asking who the resource is, should be a dedicated nurse assigned. Access to appropriate equipment is not a priority when deciding to accept an assignment, as this is usually provided.

The nurse is assessing the client with a sigmoid colostomy. The client reports frequent soft stools from the stoma. What statement by the nurse is appropriate? A) "Loose and watery stools are expected with this type of ostomy." B) "Foods like applesauce and bananas can help with diarrhea." C) "Wait to empty your pouch until it is 3/4 of the way full." D) "Reduce your fluid intake until the diarrhea subsides."

B) "Foods like applesauce and bananas can help with diarrhea." Rationale: Diarrhea may occasionally occur in a client with a sigmoid colostomy, however, the typical stool is firmer or more like a paste compared to a higher ostomy placement. Foods such as applesauce and bananas can help with diarrhea. Ostomy pouches should be emptied once they are half full to prevent leakage. Fluid intake should be encouraged to prevent dehydration.

The nurse is reviewing the plan of care with a client who has a prescription to remain supine for 24 hours following a procedure. Which statement should the nurse make to the client regarding positioning? A) "Keep your knees flexed." B) "Place a pillow under your legs." C) "Rotate your hips side to side to relieve pressure." D) "Raise your arms over your head to stretch."

B) "Place a pillow under your legs." Rationale: When caring for a client with a prescription for the supine position, the nurse should implement interventions to prevent pressure injuries. The supine position increases pressure on the client's heels and coccyx. To alleviate this pressure, the nurse should instruct the client to keep a pillow under their legs, this will float the heels off the bed and prevent pressure. Instructing the client to keep knees flexed will increase pressure on heels. Raising arms above the head does not reduce pressure. Rotating hips can increase pressure.

While walking past a client's room, the nurse hears an unlicensed assistive personal (UAP) talking to another UAP. Which statement made by the UAP would require the nurse to intervene? A) "I'll come back and make the bed after I go to the lab." B) "Since I am late for lunch, would you perform my client's blood glucose test?" C) "This client seems confused, we need to watch the client closely." D) "If we work together we can get all of the client care completed."

B) "Since I am late for lunch, would you perform my client's blood glucose test?" Rationale: Only registered nurses (RNs) and licensed practical or vocational nurses (LPN/VNs) can assign tasks and activities. UAPs cannot re-assign tasks or activities to other UAPs. Nurses are accountable for all nursing care; if UAPs cannot complete assignments, they should notify the nurse, who will reassign the task.

A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client's health care provider? A) "My neighbors just don't visit me anymore since I came home from the hospital." B) "When I emptied my urine catheter drainage bag it looked like rusty-colored water." C) "I really don't want home-delivered meals any longer. I am just not hungry." D) "I just didn't sleep well the last few nights. I keep having sad thoughts running through my mind."

B) "When I emptied my urine catheter drainage bag it looked like rusty-colored water." Rationale: The change in the color of urine to "rusty" suggests blood, a potential sign of an infection or other urinary-renal complication. This requires immediate reporting, documentation, and further assessment. The other statements do not require immediate interventions, but should also be addressed as they could indicate depression, social isolation, or an underlying, undiagnosed physical problem.

A client scheduled for surgery with general anesthesia refuses to remove their dentures prior to leaving the unit for the operative room. What would be the most appropriate nursing action? A) Notify the operating room nurse and the anesthesia department of the client's refusal B) Ask the client if they would prefer to remove their dentures in the perioperative area C) Explain to the client that the dentures must come out as they may get lost or broken in the operating room D) Ask the client why they are refusing to take their dentures out prior to the procedure

B) Ask the client if they would prefer to remove their dentures in the perioperative area To foster a professional relationship with the client, the nurse should inquire about personal preferences. Clients anticipating surgery may experience a variety of fears. Allowing the client a choice and a sense of control over the situation fosters the client's self-esteem and self-concept.

The unlicensed assistive personnel (UAP) reports to the nurse that the client with diabetes type 2 has a bedside glucose of 65 mg/dL. Which action would be a priority for the nurse? A) Instruct the UAP to give the client a snack of peanut butter and whole milk. B) Assess the client's level of consciousness (LOC). C)Administer prescribed 50mL of dextrose 50% in water (DW50%). D) Encourage the client to drink ½ cup of orange juice.

B) Assess the client's level of consciousness (LOC). Rationale: The first action the nurse should take for a client who is experiencing hypoglycemia is to assess the client's LOC, this will determine which intervention to implement. For a client who has a decrease in LOC, the nurse should administer prescribed 50mL of dextrose 50% in water. For the client who is alert and can follow commands, the nurse can encourage the client to drink ½ cup of orange juice. The nurse should assess the client before instructing the UAP to give the client a snack.

The nurse is caring for a client who has had a benzodiazepine dependency for the past several years. The client is now in an outpatient detoxification program and the nurse is teaching the client about detoxification. Which instruction should be a priority for the nurse to include in this patient's plan of care? A) Expect mild physical symptoms B) Avoid alcohol use during this time C) Discontinue the drug by weaning D) Rise slowly from a lying to standing position

B) Avoid alcohol use during this time Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage under the health care provider's direction. During this time, alcohol must be avoided. The other options are correct. However, the question asks for a priority, which is the correct answer.

A nurse receives a prescription to administer oxytocin for induction of labor in a client. Which clinical manifestation indicates an expected response to the medication? A) Absence of uterine bleeding B) Duration of uterine contractions last 50 seconds C) Uterine contractions occur every 1 minute D) Increased uterine tone

B) Duration of uterine contractions last 50 seconds Rationale: Oxytocin is a uterine stimulant used to induce labor and promote effective uterine contractions. Effective contractions occur every 2 to 3 minutes and last 45 to 60 seconds. Absence of uterine bleeding is an expected response postpartum. Uterine contractions that occur every minute do not allow the uterine to rest and regain its tone. Increased uterine tone is an expected response postpartum to avoid hemorrhage.

The hospital staff requests that parents who have a Greek heritage remove the amulet from around their infant's neck. The parents refuse. The nurse should understand the parents may be concerned about which factor? A) Fright from spiritual beings B) Evil eye or envy of others C) Balance in body systems D) Mental development delays

B) Evil eye or envy of others In the Greek heritage the matiasma, "bad eye" or "evil eye, " results from the envy or admiration of others. The belief is that the eye is able to harm a wide variety of things, including inanimate objects and that children are particularly susceptible to attacks. Persons of Greek heritage employ a variety of preventive mechanisms to thwart the effects of envy. One of these is the protective charm in the form of an amulet that consists of blessed wood or incense.

The nurse is caring for a client diagnosed with bacteremia who is experiencing acute kidney injury. The client has received fluids, but uremia persists. Which of the following interventions will the nurse prepare to implement? A) Administration of intravenous diuretics B) Initiation of continuous renal replacement therapy C) Infusion of vasodilators D) Electrolyte replacement with potassium chloride

B) Initiation of continuous renal replacement therapy Rationale: Decreased renal perfusion associated with intravascular volume depletion (e.g., from vomiting or diarrhea) or decreased arterial pressure (sepsis) results in a reduced glomerular filtration rate in prerenal acute kidney injury. Therefore, the treatment begins with fluids instead of diuretics and vasodilators in this client's scenario. Because the uremia has not improved, the next step is supportive management through continuous renal replacement therapy. Hyperkalemia is a common complication in acute kidney injury so electrolyte replacement would not be warranted.

The nurse is caring for a pediatric client who is experiencing a febrile seizure. Which action should the nurse take first? A) Administer anticonvulsant medication B) Protect the child's head from injury C) Loosen any clothing around the neck D) Apply a cooling blanket over the client

B) Protect the child's head from injury Rationale: Protecting the child from injury would be the highest priority action. Seizure activity may cause the child to have involuntary movements which could result in hitting their head. Loosening the clothing will help maintain the airway but would not be done first. The cooling blanket can help reduce the fever but would not be done first. Administering anticonvulsant medication would not happen first.

An incident report was submitted by a nurse for a client who sustained an unwitnessed fall. Which unit practice indicates an expected response to the incident report? A) The unit manager holds a meeting to present statistics on unwitnessed client falls. B) Signs indicating a "no pass zone" are posted throughout the unit. C) Every client on the unit is placed under fall risk precautions. D) All call light alarms are rerouted to the front desk.

B) Signs indicating a "no pass zone" are posted throughout the unit. Rationale: No pass zones are intended to provide rapid care to clients requesting help. Any staff member walking through a zone with an activated call light is required to assess the client's needs and request help as needed. This practice indicates an expected response to the incident report regarding unwitnessed falls. Holding a meeting to present statistical information does not implement a new practice to reduce fall risk. Not every client requires fall risk precautions. Each client should be individually assessed for this need. Call lights should be able to be answered by staff members throughout the unit. Rerouting all call light alarms may delay care.

During a counseling session, a partner verbalizes concern because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. Which approach should the nurse use to explain what is occurring? A) Detaching or dissociating in this way postpones painful feelings B) Such fantasies can gratify unconscious wishes or prepare for anticipated future events C) Converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership D) Isolating the feelings in this way reduces conflict within the client and with others

B) Such fantasies can gratify unconscious wishes or prepare for anticipated future events Fantasy, or imagined events such as daydreaming, can be used to express unconscious conflicts or to gratify unconscious wishes. The other options cannot be applied to this situation with the information provided.

The nurse is performing hand hygiene before providing care to a group of clients. The nurse should identify that the use of alcohol-based hand sanitizer would be contraindicated in which of the following clients? A) The client with a positive Methicillin-resistant Staphylococcus aureus (MRSA) infection B) The client receiving treatment for Clostridium difficile C) The client who has a history of Mycobacterium tuberculosis D) The client that developed a Escherichia coli urinary tract infection

B) The client receiving treatment for Clostridium difficile Rationale: Alcohol-based hand sanitizers are an alternate way to perform hand hygiene. However, the nurse should use soap and water when caring for clients with Clostridium difficile, which is a gram-positive, spore-forming bacteria that is not killed with alcohol. The nurse can use alcohol-based hand sanitizers with clients who have other nosocomial infections.

The nurse is developing the plan of care for a group of assigned clients. Which client should the nurse identify as having the highest risk for developing a pulmonary embolism? A) The client who had a laparoscopic appendectomy and is ambulating with assistance. B) The client who had a left hip arthroplasty and is unable to bear weight. C) The client who had a cataract extraction and has a prescription to avoid bending over. D) The client who had a heart catherization and is on bedrest.

B) The client who had a left hip arthroplasty and is unable to bear weight. Rationale: A pulmonary embolism (PE), a clot or obstruction in the pulmonary artery or vasculature, usually develop from a deep vein thrombosis. The risk factors for a PE include prolonged immobility, surgery, especially of the pelvis and lower extremities, history of DVT, oral contraceptives, smoking cigarettes, and air travel. The client who had a left hip arthroplasty has multiple risk factors, where the other clients do not.

A nurse is assessing a client who has a puncture wound of the left foot. Which findings would best indicate to the nurse that the client has developed localized osteomyelitis? A) The client reports numbness in the toes of the affected foot. B) The client's skin has erythema over the affected foot. C) The client's skin is non-blanchable around the wound. D) The client reports feeling chills.

B) The client's skin has erythema over the affected foot. Rationale: When assessing a client with a puncture wound of the left foot who is developing localized osteomyelitis the nurse will observe localized erythema and edema over the affected foot. The client will report pain in the affected, numbness in the toes is associated with peripheral vascular disease. Non-blanchable skin would indicate a decrease in perfusion, not infection. The client would report feeling chills if the infection becomes systemic.

A charge nurse is performing the daily check of the code cart on the unit. Which finding will the nurse report immediately for further inspection? A) The oxygen tank is empty B) The defibrillator charging light is off C) One of the wheels on the cart does not lock D) The last inspection is not signed

B) The defibrillator charging light is off Rationale: A defibrillator should always be fully charged in case of emergencies. Drained batteries can result in equipment failure. The oxygen tank is required for transport. However, the tank can be replaced with a full tank from the unit. The wheel locks prevent the crash cart from moving. Although the wheel needs to be inspected, it is not a priority action. Inspection signatures are important for quality improvement and documentation. However, ensuring the defibrillator is charged is the priority.

The nurse is reviewing written education with a client. The nurse notes the client squinting and moving the document close to their eyes. What assessment tool would be used to collect additional information about this patient's problem? A) snellen chart B) jaeger test C) confrontation test D) Ishihara cards

B) jaeger test Rationale: The Snellen chart is used to assess far vision; the Jaeger test is used for near vision. Confrontation tests assess visual field and peripheral field deficits. Ishihara cards assess for the ability to differentiate color.

The nurse is reviewing the ABG results for a client who was admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Which result should indicate to the nurse that the client's condition is getting worse? A) pH 7.35 CO2 43 HCO3 24 PaO2 80 B) pH 7.28 CO2 60 HCO3 26 PaO2 55 C) pH 7.32 CO2 45 HCO3 20 PaO2 83 D) pH 7.47 CO2 33 HCO3 23 PaO2 70

B) pH 7.28 CO2 60 HCO3 26 PaO2 55 Rationale: COPD is over inflation of lung tissue caused by a loss of elasticity. Clients with COPD are unable to completely exhale, resulting in an accumulation of carbon dioxide (CO2). The retention of CO2 over time can lead to respiratory acidosis, as evident by an elevation of pH and CO2 levels on the arterial blood gas.

A nurse is evaluating laboratory data of a client who received 2 units of fresh frozen plasma. Which value will the nurse review as an indication of therapy effectiveness? A) hemoglobin level B) prothrombin time C) albumin level D) platelet count

B) prothrombin time Rationale: Fresh frozen plasma (FFP) is administered for the replacement of coagulation factors. Prothrombin time provides a measure of blood clotting time and is one of the lab values used to assess effectiveness of FFP administration. The hemoglobin level is used to assess the effectiveness of packed red blood cell administration. Albumin level is used to evaluate the administration of albumin, a blood product. Fresh frozen plasma is not administered specifically for platelet deficiencies. Decreased platelet levels are treated with platelet concentrates.

The nurse is assessing the safety to discharge a client home who requires assistance with ambulation. Which statement is the priority for the nurse to make? A) "Who do you live with?" B) "What equipment will you need?" C) "Does your home have a second floor?" D) "What type of flooring do you have in your home?"

C) "Does your home have a second floor?" Rationale: When planning a safe discharge, the nurse should assess the client's home environment for safety issues. For a client who requires assistance with ambulation, the nurse should assess if the client has factors that could increase the risk of falls or injury, such as stairs. It is important to know who lives with the client but is not the priority. It is the responsibility of the nurse to evaluate what equipment the client will need.

A nurse is providing discharge instructions on medication therapy to a client with a verapamil prescription. What will the nurse include in the teaching? A) "Skip your dose if your heart rate is less than 70 beats/min." B) "You may experience some swelling in your hands and feet but this is normal." C) "Follow-up with your cardiologist as soon as possible for evaluation of treatment." D) "Your calcium levels will need to be checked every month."

C) "Follow-up with your cardiologist as soon as possible for evaluation of treatment." Rationale: The nurse should encourage the client to follow up with their provider as soon as possible. Verapamil has several drug interactions and side effects that can cause heart block and organ dysfunction if not monitored frequently. Verapamil should be held if the heart rate is less than 50 beats/min. Peripheral edema is a complication of verapamil. The client should be instructed to contact their healthcare provider if this occurs. Verapamil is a calcium-channel blocker. However, this mechanism does not affect total serum calcium levels.

The preoperative nurse is witnessing a client sign consents for surgery. The client states, "I am not sure if I should have the surgery." Which statement would be appropriate for the nurse to make? A) "I will let your healthcare provider know your feelings." B) "This is a hard decision for you to make." C) "Tell me more about what makes you think you do not want the surgery." D) "You should talk to your family about your concerns."

C) "Tell me more about what makes you think you do not want the surgery." Rationale: The nurse's role with informed consent is to the witness the client's signature of the consent. If the client expresses concerns, the nurse should gather more information about the client's feelings. The nurse should alleviate the client's anxiety by allowing the client to discuss their feelings and concerns. The nurse would notify the healthcare provider if the client refuses the surgery or has specific questions about the surgery.

A nurse is assessing a client with a continuous IV infusion. The client verbalizes pain at the venous access site. The nurse notes erythema at the site with a palpable venous cord. How will the nurse grade the severity of phlebitis? A) 1 B) 2 C) 3 D) 4

C) 3 Rationale: Phlebitis is graded using a 0-4 scale, with 0 being no symptoms or complications, and 4 having multiple criteria with concerning complications. A grade of 3 includes pain at the access site with erythema, edema, streak formation, and a palpable venous cord. Grade 1 is indicated by erythema with or without pain. Grade 2 is characterized by erythema and pain. Grade 4 is characterized by all symptoms in grade 3, with the addition of purulent drainage.

A nurse is teaching a client about the use of ego defense mechanisms. Which information will the nurse share with the client? A) Use of a defense mechanism is always apparent to the client B) Use of defense mechanisms is always viewed as an unhealthy coping strategy C) Adaptive use of defense mechanisms helps the client manage anxiety D) Most people typically use one type of defense mechanism

C) Adaptive use of defense mechanisms helps the client manage anxiety Ego defense mechanisms are automatic coping strategies used by people to protect from anxiety and/or maintain self-image. They can be adaptive or maladaptive in nature. Adaptive use helps people lower anxiety and achieve goals in acceptable, healthy, and appropriate ways. Maladaptive coping tends to be more primitive in nature and viewed as unhealthy. Defense mechanisms are not always evident to the individual using them. Most people use a variety of coping mechanisms.

The nurse is participating in the implementation of a hospital's disaster response plan. Which of the following indicates correct understanding of disaster planning? A) All hospital staff must receive training on identifying signs of bioterrorism activities within the community. B) All hospital staff must receive training on handling of hazardous materials and decontamination. C) Annual drills are required and should include community-wide resources with a simulation of a large influx of clients. D) The hospital pharmacy is required to stockpile antibiotics and nerve agent antidotes in the event of a bioterrorist attack.

C) Annual drills are required and should include community-wide resources with a simulation of a large influx of clients. Rationale: All facilities are required to carry out internal and external disaster drills, one of which includes implementing community-wide resources and simulation of a large influx of clients in the event of a disaster. Typically, nurses, emergency department physicians and other medical providers are required to receive training on handling hazardous materials, decontamination and recognizing patterns of illness that indicate potential bioterrorism in the community. While it is ideal for pharmacies to stockpile antidotes to nerve agents and antibiotics, this is not a federal requirement, although resources are becoming more available for facility pharmacies to obtain these medications.

The nurse has been managing the care of a home health client for six weeks. In order to determine the quality of care being provided to the client by a home health aide, what should be the priority action by the nurse? A) Ask the client if they are satisfied with the care given by the home health aide B) Investigate if the home health aide is prompt and stays an appropriate length of time C) Determine if the home health aide's care is consistent with the plan of care D) Check the documentation of the home health aide for accuracy

C) Determine if the home health aide's care is consistent with the plan of care Rationale: Home health care allows clients to receive care in the home. Clients receive quality care from home health aides, who are supervised closely by registered nurses. The client's feedback is important, as it could impact their plan of care. The client's engagement in the plan of care is recommended. It is important that the nurse investigates the accuracy of documentation, promptness, and length of stay by the home health aide. These are essential characteristics of a health care worker. These characteristics could also impact employment, as they are a component of professional behavior. Although the nurse must investigate all of these things, the first priority is an evaluation of the adherence to the plan of care. The plan of care is based on the reason for referral, the provider's orders, the initial nursing assessment, and the client's responses to the planned interventions. It is what justifies the care of the client.

The nurse is preparing to perform continuous bladder irrigation (CBI) for a client who had prostate surgery. Which action is correct for the nurse to take? A) Deflate the catheter balloon B) Place the client in supine position C) Purge the air from the tubing prior to connecting to the catheter D) Clamp the tubing above the access port

C) Purge the air from the tubing prior to connecting to the catheter Rationale: When providing continuous bladder irrigation, purge the air from the tubing to ensure that no air enters the system, similar to IV tubing. The client should be in semifowlers for CBI. The catheter balloon should not be deflated, or the catheter may dislodge. When performing intermittent irrigation, the catheter may be clamped below the access port.

The nurses on a medical unit are participating in a quality improvement project to promote clients' sleep and rest. Which of the following actions should be implemented? A) Plan admissions to the unit during daylight hours B) Silence the alarms in the nursing station C) Schedule afternoon and nighttime "quiet time" hours D) Turn off all lights in the clients' rooms at night

C) Schedule afternoon and nighttime "quiet time" hours Rationale: In this hospital, unfamiliar noises, such as people walking by or entering and leaving the room and the sounds of elevator doors, bring complaints from patients in health care facilities. Many health care facilities have made attempts to transform their patient care areas into quieter settings that facilitate rest and sleep. Attention to design features with a focus on eliminating environmental noise, providing patients with private rooms, and formal quiet times on units all are aimed at creating an environment that is conducive to good sleep. Alarms are a safety feature and should not be silenced. Admissions are nearly impossible to schedule as emergencies happen 24/7. Turning off lights may increase the risk of falls and injuries.

The nurse is documenting on the plan of care of a client who had a right total knee replacement. The nurse is utilizing a clinical pathway for the client's care. Which should the nurse identify as the purpose of a clinical pathway? A) Provide client information for the healthcare team. B)Identify critical information about the client's condition. C) Standardized expected client outcomes based on clinical guidelines. D) A diagram to organize data to identify client problems.

C) Standardized expected client outcomes based on clinical guidelines. Rationale: There are different formats to develop and document the client's plan of care. A concept map care plan uses a diagram to represent client problems and interventions and is organized by client data. Change of shift reports focuses on the critical client information being communicated between nurses for continuity of care. Computerized care plans are accessible by anyone on the healthcare team to access client information. Clinical pathways are standardized, interdisciplinary care based on evidenced-based clinical guidelines for a specific condition or illness.

The nurse is caring for a group of assigned clients with malnutrition. Which client would be the most appropriate candidate for enteral nutrition? A) The client with colon cancer who has an ileus. B) The client who had a gastritis with intractable vomiting. C) The client with neck cancer who has a tracheostomy. D) The client who had an appendectomy with ischemic bowel.

C) The client with neck cancer who has a tracheostomy. Rationale: Clients with intestinal obstruction, ileus, peritonitis, intractable vomiting, and bowel ischemia are not appropriate candidates for enteral tube feeding. These clients would be candidates for parenteral nutrition. The client with neck cancer who had a tracheostomy would be an appropriate candidate for enteral nutrition.

The nurse witnesses a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) in front of other staff members present. The UAP does not react or respond to the HCP's comments. What is the best action by the nurse? A) Notify the chief of the medical staff about the HCP's breach of professional conduct B) Encourage the UAP to directly confront the HCP about the unprofessional behavior C) Walk up to the HCP and quietly state, "This unacceptable behavior has to stop." D) Complete an incident report describing the HCP's unprofessional behavior

C) Walk up to the HCP and quietly state, "This unacceptable behavior has to stop." Rationale: The QSEN competency Teamwork and Collaboration requires the nurse to function effectively within nursing, working with inter-professional teams, and fostering open communication and mutual respect. The nurse should first approach the HCP to stop the behavior and then attempt to discuss communication styles that diminish the risks associated with authority gradients among team members. Notifying the chief of the medical staff might be necessary in the future if the HCP continues to act unprofessionally toward the staff. Directly confronting the HCP would most likely cause the HCP to become defensive and should be avoided. Completing an incident report is not necessary at this time.

The nurse is assessing a client who has hyperthyroidism and notes the client's heart rate is 150 and oral temperature is 101.3F (38.5C). The nurse suspects the client is experiencing thyroid storm. Which action should the nurse take first? A) administer prescribed IV dextrose fluids B) administer prescribed propranolol C) apply a hypothermic blanket D) reduce environmental stimuli

C) apply a hypothermic blanket Rationale: Thyroid storm, or acute thyrotoxicosis, is a systemic syndrome due to excessive amounts of thyroid hormones in circulation and is considered a medical emergency. The client will experience hyperthermia, severe tachycardia, and seizures. The first action of the first is to decrease core temperature by applying a hypothermic blanket. Then, the nurse will decrease heart rate with propranolol, decrease dehydration with prescribed IV dextrose fluids, and prevent seizures with reduction of environmental stimuli.

The nurse is assessing a client who has a suspected right hip fracture following a fall. Which of findings would require immediate follow up by the nurse? A) edema and ecchymosis over the right hip B) right leg appears shorter than the left leg and client report pain level of 6 C) diminished pedal pulse and capillary refill greater than 3 seconds in the affected extremity D) adduction of the affected extremity and loss of function

C) diminished pedal pulse and capillary refill greater than 3 seconds in the affected extremity Rationale: When assessing a client with a suspected right hip fracture, the nurse should expect to observe the client's affected extremity will be abducted, appear shorter than the unaffected extremity, and have edema and ecchymosis. A client with a diminished pedal pulse and capillary refill greater than 3 seconds would indicate that the client is experiencing a decrease in perfusion in the affected extremity, which would require immediate follow up by the nurse.

The nurse is assisting a client newly diagnosed with diabetes type I with meal planning exchanges. Which food choice made by the client would be appropriate? A) beef patty on bread, French fries, ½ cup of watermelon, and diet soda B) broiled fish, one cup of rice, green beans, and ice water C) one cup of cooked pasta with grilled chicken, broccoli, and olive oil, one cup of strawberries, and unsweetened iced tea D) two cups of lettuce, tomatoes, and cucumbers with ranch dressing and sugar free gelatin with peaches

C) one cup of cooked pasta with grilled chicken, broccoli, and olive oil, one cup of strawberries, and unsweetened iced tea Rationale: Diabetic meal planning exchange lists are an easy way for clients to adequately choose appropriate foods. With the exchange list, the client will choose a number of helpings of food from the list for each meal and snack. The client will choose a starch, fruit, vegetable, meat, fats, and free foods. The meal should include a food from each list.

The nurse is monitoring a client who is postoperative 6 days following a single-lung transplantation. Which of the following findings should the nurse report to the healthcare provider immediately? A) client reports incisional pain B) diminished breath sounds C) oxygen desaturation with ambulation D) serosanguinous drainage observed on dressing

C) oxygen desaturation with ambulation Rationale: The client who is postoperative single-lung transplantation is at risk for acute rejection which can occur in the first 10 days. The nurse should monitor the client for oxygen desaturation, low grade fever, dyspnea with exertion, and a dry cough. The other options are normal findings following lung surgery.

The parents of a 4-year-old boy have just been informed that their son has a congenital neurologic disorder that is terminal. The nurse should anticipate the parents' reaction to fall into which crisis phase? A) impact phase B) crisis phase C) pre-crisis phase D) resolution phase

C) pre-crisis phase A crisis is a sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. The development of a crisis situation follows a relatively predictable course. Stages in a crisis go from the pre-crisis phase (phase 1) , to the impact phase (phase 2), then the crisis phase (phase 3), and finally the resolution phase (phase 4). The time frame of recent bad news places the parents in phase 1. In this phase, an individual is exposed to a precipitating stressor, resulting in increased anxiety and employment of previous problem-solving techniques.

During the management of a client's pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client's pain? A) clients have the right to have their pain managed promptly B) nurses housed not judge a client's pain based on the nurses values C) the clients self-report of pain is the most important consideration D) cultural sensitivity is fundamental to client-centered pain management

C) the clients self-report of pain is the most important consideration Rationale: Pain is a complex phenomenon that is perceived differently by each individual. A client's self-reported pain serves as the foundation for the nurse's approach to pain management. The nurse shall keep in mind that pain is subjective and accept the client's report of pain in a nonjudgmental and objective manner. Client-centered and ethical nursing care requires that the nurse recognizes their personally held values and beliefs about the management of pain and that the client's expectations, values, and beliefs influence outcomes in the management of their pain.

The nurse is caring for a client who was seriously injured in a bus accident. Several people were killed in the accident, including the client's son. The client's spouse, who was not injured, has had frequent outbursts of yelling at the staff. The client's spouse is now threatening legal action due to "inadequate care." Which interventions should the nurse implement? Select all that apply. A) Notify the health care provider about the situation. B) Notify hospital security to remove the client's spouse. C) Provide information about grief support groups. D) Request a change in client assignment. E) Allow the spouse to express their feelings.

C,E Anger and frustration are common reactions when a person is experiencing a sudden, traumatic loss. The nurse should allow the spouse to verbalize their feelings because this can help with the grief process. The nurse can provide both the client and spouse with referrals to grief support groups. Notifying the health care provider is not needed at this time. Presently, the spouse is not posing a danger to the client, staff or other visitors so removal is not needed. Changing the client assignment would not facilitate a therapeutic nurse-client relationship and the development of trust between the client, the client's spouse and the health care team.

The community health nurse is discussing concerns with a client during a family assessment. The client states "How do we ensure our adolescent will not experiment with drugs." Which is the best statement for the nurse to make? A) "Set clear boundaries that are enforced." B) "Discuss the risks of doing drugs." C) "Monitor social media activity." D) "Engage in family activities several times a week."

D) "Engage in family activities several times a week." Rationale: Substance use and abuse is major stress and issue with families. To decrease the risk for substance abuse and use in children, families should be encouraged to engage in activities together, close relationships with the family and modeling behavior by family members. Strict boundaries, discussing the risks and monitoring social media are not preventive measures.

The graduate nurse is interviewing with a nurse manager. Which statement by the graduate nurse would best assess safe staffing of the unit? A) "How many nurses work on the unit?" B) "Are the client acuity levels high?" C) "Who is responsible for developing assignments?" D) "What is the frequency of floating to other units?"

D) "What is the frequency of floating to other units?" Rationale: Before accepting employment, the graduate nurse should assess safe staffing. The graduate nurse should ask about frequency of floating, which means nurses need to cover other units and is a sign of inadequate staffing. Asking about the number of nurses does not assess staffing, because of the factors of client acuity and experience of nurses. Developing of assignments is about division of work, not staffing.

The nurse is counseling a client who is postpartum who has a history of a substance-abuse problem. Which question is a priority when interviewing the client? A) "Do you feel that you have bonded with your infant?" B) "Have you attended any support groups related to substance abuse?" C) "How have you managed the stress of being a new mother?" D) "When was the last time you used illegal substances?"

D) "When was the last time you used illegal substances?" While all of the questions are appropriate, it is essential to assess whether or not the mother is still abusing illegal substances. This would pose a risk for the client and the newborn. The other questions are appropriate to ask after assessing for recent substance abuse.

A nurse is providing discharge instructions on medication administration to a client prescribed ipratropium via a metered-dose inhaler. What will the nurse include in the teaching? A) "Hold your breath for 3 to 5 seconds after pressing the inhaler." B) "Avoid shaking the inhaler prior to administration." C) "Press the inhaler after you breathe out completely." D) "You may place the inhaler 1 to 2 inches away from your mouth during administration."

D) "You may place the inhaler 1 to 2 inches away from your mouth during administration." Rationale: Positioning the inhaler 1 to 2 inches away from the mouth is an acceptable way to administer the medication. The client may also be instructed to place their lips around the mouthpiece for administration. The nurse should instruct the client to hold their breath for 10 seconds to allow the medication to reach the lungs. Shaking the inhaler ensures the medication is mixed properly before administration. The inhaler should be pressed at the start of inhalation to ensure the medication is absorbed properly.

A charge nurse is assigning a room to a client with a history of moderate Alzheimer's. The charge nurse will assign the client to a room in which area of the unit? A) Next to the client activity room B) At the end of the hallway C) In front of the elevator D) Across from the medication room

D) Across from the medication room Rationale: Clients with moderate Alzheimer's may have personality and behavioral changes that lead them to wander and get lost. Medication rooms are frequently used by nurses. This placement ensures frequent visual checks of the client. Assigning the client to a room at the end of the hallway is not appropriate. Most stairwells are at the end of hallways and can be an area for the client to escape. A room in front of the elevator is not appropriate for a client with Alzheimer's. Assigning the client next to an activity room provides overstimulation. Noise should be kept to a minimum.

A nurse is preparing to perform an ear irrigation on a client. Which precaution will the nurse take to prevent acute otitis externa? A) Ensuring proper control of the irrigation syringe B) Inspecting the auditory canal prior to the procedure C) Using a sterile irrigation solution D) Drying the outer ear canal with a cotton ball

D) Drying the outer ear canal with a cotton ball Rationale: Acute otitis externa is an ear infection caused by retained moisture. Drying the outer ear canal with a cotton ball ensures any remaining irrigation fluid is removed. Proper control of the irrigation syringe prevents damage to lining of the ear canal. Inspection of the auditory canal verifies ear structures are intact. However, this does not prevent a possible infection. The irrigation solution to be used will be prescribed by the healthcare provider. Not all ear solutions are sterile.

The nurse is caring for a client on who has been newly prescribed glyburide. When assessing the client's allergies, the client reports an allergy to trimethoprim and sulfamethoxazole (SMX-TMP). What action by the nurse is appropriate? A) Inform the client that it is safe to take the glyburide because it is not for the same indication as the SMX-TMP B) Administer the glyburide because it is not in the same drug class at the SMX-TMP C) Review the drug databank to determine if there is an interaction between glyburide and SMX-TMP D) Hold the glyburide and inform the healthcare provider

D) Hold the glyburide and inform the healthcare provider Rationale: Glyburide is a sulfonylurea and may cause an allergic response in client allergic to sulfa based medications. The medication should be held and the healthcare provider notified. Reviewing the drug databank for interactions between the two medications does not address the client's safety need and is not relevant to this situation.

The nurse is assisting a client with denture care. Which of the following actions is appropriate? A) Use toothpaste when brushing the dentures B) Leave the dentures to air dry C) Rinse the dentures in hot water D) Line the sink with a towel when cleaning

D) Line the sink with a towel when cleaning Rationale: Dentures should be soaked in and brushed with a nonabrasive denture cleanser. Hot water may warp the plastic used to make the denture. Similarly, leaving them to air dry may cause warping. Lining the sink may prevent damage to the dentures if they are accidentally dropped.

A nurse is preparing to transfer a client who has been on bed rest to a chair. Which action should the nurse take first? A) Place a transfer belt on the client. B) Position the bed at an appropriate height. C) Assist the client to a seated position. D) Obtain orthostatic vital signs.

D) Obtain orthostatic vital signs. Rationale: A client who has been on bed rest is at risk for orthostatic blood pressure, due to the decrease of venous return from muscle contraction. Before moving a client, who has been on bed rest, the nurse should assess orthostatic blood pressure first. Then the nurse will position the bed at an appropriate height, assist the client to a seated position, and then place the transfer belt on the client.

The nurse is reviewing the laboratory data for a client with a pulmonary embolism who has a new prescription for heparin. Which of the following results should the nurse report to the healthcare provider? A) Hematocrit 45% B) Partial Thromboplastin time (PTT) 65 seconds C) White blood cell count 8,000/mm3 D) Platelet count 74,000/mm3

D) Platelet count 74,000/mm3 Rationale: Clients who are receiving prescribed anticoagulant therapy are at risk for bleeding and thrombocytopenia, which would be low hematocrit and platelet counts. This hematocrit is within the expected reference range of 37-47% in females and 42-52% in males. The desired therapeutic range for anticoagulation is between 1.5-2 times the expected reference range, or 60-80 seconds. A PTT of 65 seconds is within the expected reference range for anticoagulation. The expected reference range for platelets is 150,000-400,000/mm3.

The nurse identified a need for practice change. Which action should the nurse take to implement the practice change? A) Review the change to the nurse manager. B) Discuss the change with other staff members. C) Submit a proposal to hospital administration. D) Present the change with shared governance group.

D) Present the change with shared governance group. Rationale: Shared governance is a framework for nurses in direct are to create and maintain the optimal nursing practice setting through actively participating in decision making. When a nurse identifies the need for a practice change, the nurse should present the change with shared governance group.

The emergency room nurse is caring for a client who sustained a basilar skull fracture in a motor vehicle accident. Which of the following findings best indicates that the client is experiencing a cerebrospinal fluid leak? A) bright, red fluid draining from ear B) sticky, serous fluid that is negative for glucose draining from the nose C) greenish drainage with foul odor draining from the nose D) clear drainage from ear that separates into rings on gauze

D) clear drainage from ear that separates into rings on gauze Rationale: The client with a basilar skull fracture is at risk for a cerebrospinal fluid leak. The finding associated with a CFS leak would be the drainage of clear fluid, that is positive for glucose and separates into rings on a piece of gauze. Sticky serous fluid is associated with rhinorrhea that occurs with allergies. Greenish drainage with foul odor draining from the nose is associated with an infection. Bright red draining occurs with epistaxis, a bloody nose.

The nurse is assessment for an older adult client with a urinary tract infection. Which finding would require immediate follow up by the nurse? A) bladder distention B) costovertebral tenderness C) dysuria D) confusion

D) confusion Rationale: An older adult client with urinary tract infection is at an increase risk for sepsis, where the infection is has become systemic. An older adult client with a UTI who is experiencing systemic infection will have hypotension and confusion. Bladder distension, dysuria, and costovertebral tenderness are expected findings of a UTI.

The nurse is monitoring a client who sustained a spinal cord injury. Which assessment finding would best indicate the client is experiencing neurogenic shock? A) pulse pressure 40 B) peripheral edema C) bladder distention D) heart rate 50

D) heart rate 50 Rationale: Neurogenic shock occurs when the parasympathetic system (PNS) becomes unopposed due to a loss of the sympathetic nervous system from a spinal cord injury. The PNS, which is responsible for the rest and digest stimulation, such as digestion and urination. Overstimulation of the PNS causes vasodilation, bradycardia, and temperature deregulation. Peripheral edema and bladder distention are complications that can occur with spinal cord injuries but is not a finding of neurogenic shock. A pulse pressure of 40 is normal.

The nurse is caring for a client who practices Chinese medicine. Which of the following therapeutic goals would be the priority for the client? A) maintain a balance of energy B) achieve harmony C) respect life D) restore yin and yang

D) restore yin and yang For followers of Chinese medicine, health is maintained through the balance between forces of yin and yang. According to Chinese medicine, the body is held together by meridians; which are connected in terms of structure, function, and pathology. Chinese medicine views the body as a balance of yin (cold) and yang (hot) forces. Maintaining a balance between yin and yang achieves health and wellness. Within Chinese medicine, disease is believed to arise from an internal imbalance of the two, leading to a blockage in the flow of energy and of blood along the body's meridians. Using Chinese medicine restores flow and maintains the body in a state of harmony preventing illness. Methods aimed at maintaining health with Chinese medicine include acupuncture, acupressure, meditation, cupping, etc. Maintain balance of energy, achieving harmony and respect for life are not practices of Chinese medicine.

The charge nurse is observing a newly hired nurse use a fire extinguisher for a small fire in a client's room. Which action by the newly hired nurse would require intervention by the charge nurse? A) Aiming the hose at the top of the fire B) Pulling out the fire extinguisher's safety pin C) Squeezing the handle to discharge material onto the fire D) Sweeping the hose from side to side until the fire is extinguished

A) Aiming the hose at the top of the fire Rationale: Correct technique for use of a fire extinguisher includes pulling out the safety pin, aiming the hose at the base of the fire, squeezing the handle to discharge the material, and sweeping the hose from side to side. It requires intervention if the nurse is observed aiming the hose at the top of the fire instead of the base.

A nurse is observing unlicensed assistive personnel (UAP) providing perineal care to a client with urinary incontinence. Which action by the UAP prompts the nurse to intervene? A) Applies powder to the client's inner thighs B) Places alcohol-free barrier film on skin abrasions C) Bathes the client with tepid water D) Lathers the perineal area with a moisture barrier cream

A) Applies powder to the client's inner thighs Rationale: The nurse should intervene if unlicensed assistive personnel (UAP) are observed applying powder to the client's inner thighs. Powder products are abrasive and have the potential for aspiration. Barrier films that are free of alcohol can be placed over abrasions or skin that is exposed to urine to avoid further skin integrity issues. Tepid water is the acceptable temperature for bathing a client. Hot water should be avoided. Moisture barrier creams, particularly dimethicone-based, are used to repel fluid and prevent skin breakdown.

The nurse is adding sterile solution from an open container onto a prepared sterile field. Which action should the nurse take? A) Pour the sterile solution from a height of five inches B) Place the cap of the sterile solution on the table with edges down C) Pour the sterile solution immediately after opening the container D) Apply sterile gloves before opening the sterile solution container

A) Pour the sterile solution from a height of five inches Rationale: When adding sterile solution to prepared sterile field, the nurse should maintain the sterility of the solution and the field by pouring the solution 4 to 6 inches above the sterile container. When using a sterile solution container that has been opened, the nurse should place the cap with edges up and pour out solution lipping the bottle edges before pouring the solution onto the sterile field. The nurse will apply sterile gloves after pouring the sterile solution to prevent contamination.

A nurse is evaluating a client's home for fire safety. Which observation prompts the nurse to intervene? A) The client's bedding is made out of nylon material. B) Emergency numbers are taped to the back of the house phones. C) The smoke alarm batteries were last changed 3 months ago. D) There are 2 fire extinguishers in the home.

A) The client's bedding is made out of nylon material. Rationale: Materials made out of nylon can generate static electricity. The nurse should encourage the client to replace the bedding with items made from cotton. Emergency numbers should be kept within reach, particularly near a phone in case of a fire or other emergency. The batteries in the smoke alarm have been changed within an adequate timeframe. Smoke alarm batteries should be checked and changed every 6 months. Each home should have at least 1 fire extinguisher. Multi-level homes should have a fire extinguisher in each floor.

The nurse is developing the plan of care for a client who has an acute episode of diverticulitis. Which interventions should the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. A) nasogastric tube insertion and suction B) administer prescribed IV antibiotics C) bed rest D) increase intake of oral fluids E) obtain blood cultures

A, B, C, E Rationale: During the acute episode of diverticulitis, the client will require management of symptoms, which will include bowel rest with bed rest and NG tube, antibiotics to treat infection, and blood cultures to evaluate if the localized infection has become systemic. During the acute episode the client will be in NPO.

The nurse is assessing a client who has renal failure and is exhibiting manifestations of hyperkalemia. Which finding should the nurse expect to observe ? Select all that apply. One, some, or all responses may be correct. A) irritability B) irregular pulse C) abdominal pain D) vomiting E) constipation

A,B,C,D Rationale: Hyperkalemia, increase level of potassium, occurs with impaired renal secretion, cellular shift, and increase intake of potassium. For clients at risk for developing hyperkalemia, the nurse should monitor for signs such as irritability, muscle weakness, paresthesia, abdominal pain, diarrhea, vomiting, confusion, and irregular pulse. Constipation is associated with hypokalemia.

When planning care for a group of clients who are refugees, which is the priority of the nurse? A) navigating public transportation B) access to therapy C) understanding social norms D) communication barriers

B) access to therapy Rationale: Clients who are refugees often have left their homes as a result of disaster or under horrific reasons. These clients often experienced traumas, such as torture. The priority for the nurse when planning care is access to therapy. Navigating public transportation, understanding social norms, and communication barriers can impact care, but therapy is the priority.

A nurse is providing care to a client who reports constipation for the last 5 days. Upon assessment, the client suddenly has projectile vomiting with a fecal odor. Which acute condition does the nurse suspect? A) colon intussusception B) small bowel obstruction C) gastrointestinal perforation D) large intestinal volvulus

B) small bowel obstruction Rationale: Projectile vomiting with a fecal odor is characteristic of a small bowel obstruction. Pressure within the bowel causes a back up of intestinal contents, resulting in emesis with a fecal odor. Colon intussusception occurs when a part of the large bowel folds into an adjacent section. Pain and rectal bleeding are characteristic signs of this condition. Gastrointestinal perforation is characterized by sudden, intense pain with subsequent signs of sepsis. A volvulus occurs when a part of the intestine twists. Symptoms related to large intestinal conditions do not produce emesis with a fecal odor.

The nurse is assessing a client who is 8-months-old. Which of the following physical assessment findings is expected? A) The client can stand up unassisted B) The client can say simple words C) The client has two to four teeth D) The client can scribble with a crayon

C) The client has two to four teeth Rationale: At eight months of age, teeth will have begun to erupt (this starts between 6-8 months). Skills such as standing up unassisted, scribbling with a crayon or pencil and articulation of simple words do not typically begin until 10-12 months.

A nurse is preparing to administer alteplase to a client diagnosed with an acute ischemic stroke. Which laboratory value will the nurse assess prior to administering the medication? A) CK-MB B) troponin t C) aPTT D) LDL

C) aPTT Rationale: Alteplase is a thrombolytic medication used to dissolve blood clots by converting plasminogen to plasmin. Activated partial thromboplastin time (aPTT) evaluates blood clotting and is a necessary value to assess before and during therapy. CK-MB is a cardiac marker used to evaluate the presence of myocardial tissue damage. It is not a laboratory value commonly checked for the administration of alteplase. Troponin T is a cardiac enzyme that is commonly used to diagnose a myocardial infarction. Low-density lipoprotein (LDL) is a form of cholesterol that increases the risk of atherosclerosis and ischemic stroke. However, this does not evaluate the effectiveness and safety of alteplase therapy.

The nurse is caring for a client who is postoperative two hours coronary artery bypass graft. The nurse notes that the client's central venous pressure monitoring is increased. Which of the following actions should the nurse take? A) check chest tube for kinks B) increase the prescribed IV fluids C) auscultate lung sounds D) administer prescribed dopamine

C) auscultate lung sounds Rationale: A client who is post CABG is at risk for fluid volume overload and fluid volume deficit. Fluid volume overload can occur with post op heart failure. Central venous pressure measures volume, increasing pressures indicates fluid volume overload. The nurse should assess the client's lung sounds to evaluate if the client is experiencing heart failure. A decrease in central venous pressure would indicate fluid volume deficit, so the nurse would assess for signs of bleeding or administer prescribed dopamine.

The nurse is assisting a client who has hypothyroidism with meal planning. Which food should the nurse recommend the client choose? A) white rice B) packed eggs C) wheat bread D) baked chicken

C) wheat bread Rationale: The client with hypothyroidism is at high risk for constipation and should be instructed to eat foods that are high in fiber, such as wheat bread, beans, and broccoli. White rice, poached eggs, and baked chicken are not good sources of fiber and could increase constipation.

The nurse is completing discharge teaching for a client diagnosed with hepatitis A. Which statement by the client would indicate to the nurse further teaching is required? A) "I will need rest after a physical activity." B) "I should eat several small meals a day." C) "I will use a separate bathroom from my family." D) "I can resume cooking for my family when my symptoms resolve."

D) "I can resume cooking for my family when my symptoms resolve." Rationale: Hepatitis A virus is transmitted through fecal-oral route and causes flu-like symptoms. The virus can still be shed through the feces for up to 1 week after symptoms resolve, so the client should still maintain precautions. The client should rest after activity, eat small meals, and use a separate bathroom to prevent the transmission to family members.

The nurse is taking a health history from a Native American client. It is critical for the nurse to remember that eye contact with such clients may be interpreted as which behavior? A) expected B) professional C) enjoyable D) rude

D) rude Native Americans tend to consider direct eye contact to be impolite or aggressive among strangers. The nurse should not misinterpret lack of direct eye contact as a clinical symptom.