A. Quiz Questions

C (Because the rubella virus is found in the respiratory tract and urine, isolation is necessary; rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated term; the techniques used with this precaution are incorporated under contact precautions, and the techniques used with contact precautions are incorporated under standard precautions. The use of standard precautions alone is unsafe; additional precautions must be implemented to protect the nurse from droplet-transmitted infection.)

A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions should the nurse institute? A. Enteric B. Contact C. Droplet D. Standard

A (Inflating or deflating the cuff too slowly will yield false high diastolic readings. Wrapping the cuff too loosely will result in false high systolic and diastolic values. Applying the stethoscope too firmly will result in false low diastolic readings. Repeating the assessment too quickly will result in false high systolic readings.)

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? A. Inflating the cuff too slowly B. Wrapping the cuff too loosely C. Applying the stethoscope too firmly D. Repeating the assessment too quickly

BDE (Bringing in any change in the preoperative teaching protocol may require the nurse manager to develop new skills and competency required for implementing the change. Modifications should be made in the protocol to implement the change and promote client safety. Late adopters to change may try to negatively influence the change initiatives. Their influence should be minimized on the staff members implementing the change. Support from the clients may not be helpful as they might not have the necessary scientific knowledge. The non-nursing staff can be included in the change initiative for better support.)

A nurse manager wants to change the protocol of preoperative teaching to include aspects of deep breathing and infection control measures. Which strategies should the nurse implement to support this change? Select all that apply. A. Mobilizing positive support from the clients for the change B. Developing new skills and competency required for implementing the change C. Excluding the non-nursing staff from the change initiative to reduce their influence D. Making modifications in preoperative teachings to support the change initiative E. Reducing the negative influences of late adopters from the group implementing the change

D (Identifying the problem, which includes reviewing literature, formulating a theoretical framework, and identifying the study variables is similar to assessment in the nursing process. Analyzing the results of research is similar to the evaluation phase of the nursing process. Conducting the study is similar to the implementation phase of the nursing process. Developing the hypothesis coincides with the diagnosis phase of the nursing process.)

Which step in the research process is similar to the assessment step of the nursing process? A. Analyzing the results B. Conducting the study C. Developing hypothesis D. Identifying the problem

A (Unrelieved chest pain increases anxiety, fatigue, and myocardial oxygen consumption, with the possibility of extending the infarction. The client will not be ready for teaching until the chest pain is relieved. Cardiac monitoring is important, but it does not take priority over relieving the chest pain. Bed rest is necessary to decrease the workload of the heart, but decreasing the cardiac workload will be difficult to achieve unless the chest pain is relieved.)

A client is admitted to the coronary care unit complaining of "viselike" chest pain radiating to the neck. Assessment reveals a blood pressure of 124/64 mm Hg, an irregular apical pulse of 64 beats per minute, and diaphoresis. Cardiac monitoring is instituted, and morphine sulfate 4 mg intravenous (IV) push stat is prescribed. What is the priority nursing care for this client? A. Relief of pain B. Client teaching C. Cardiac monitoring D. Maintenance of bed rest

BDE (The content component involves information about the nursing interventions for clients with specific health care problems. When the nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli, this action is an example of the content component. When the nurse understands that many clients practice polypharmacy by purchasing prescribed medications from multiple stores, this understanding is an example of the content component. When the nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent spread of pathogens, this knowledge is an example of the content component. When the nurse assessing a client's medical records before surgery finds that the client is allergic to latex, this discovery is an example of the input component. When the nurse checks the medical records of the client for blood transfusion reaction before administering a blood transfusion, this action is an example of the input component.)

A nursing student is learning about the nursing process, which consists of four components. Which scenarios should the nursing student consider as content components? Select all that apply. A. "A nurse assessing a client's medical records before surgery finds that the client is allergic to latex." B. "The nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli." C. "The nurse checks the client's medical records for any blood transfusion reactions before administering a blood transfusion." D. "The nurse understands that many clients buy prescribed medications from multiple medical stores; this is known as polypharmacy." E. "The nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent the spread of pathogens."

C (The licensed practical nurse can insert an indwelling urinary catheter for clients after a hysterectomy or any other surgery. A registered nurse can insert an indwelling urinary catheter, but the task can also be performed by the licensed practical nurse. A patient care associate can only monitor and assist the client. Unlicensed nursing personnel are not qualified to insert an indwelling urinary catheter.)

Which healthcare team member is considered the priority person to insert an indwelling urinary catheter for a client who underwent a hysterectomy? A. Registered nurse B. Patient care associate C. Licensed practical nurse D. Unlicensed assistive personnel

D (The expected value of a pulse oximetry reading is 95% to 100%. Nonrebreather mask will deliver high oxygen concentrations (95% to 100%) at a liter flow of 10 to 15 L/min. When using a nonrebreather mask, the client breathes only the oxygen source from the bag. A face tent delivers 30% to 50% oxygen when set at a flow rate of 4 to 8 L/min. A Venturi mask delivers 24% to 50% oxygen when set at a flow rate of 4 to 10 L/min. A nasal cannula delivers 24% to 45% oxygen when set at a flow rate of 2 to 6 L/min.)

Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? A. Face tent B. Venturi mask C. Nasal cannula D. Nonrebreather mask

B (Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps. ***Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.)

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? A. Immediately stop the infusion. B. Lower the height of the enema bag. C. Advance the enema tubing 2 to 3 inches (5 to 7.5 cm). D. Clamp the tube for 2 minutes and then restart the infusion.

B (Stating that the client feels that she's neglected her health indicates recognition of expressed feelings; a nondirective and reflective response encourages verbalization. Asking the client why she waited so long ignores the client's current emotional needs; direct statements often do not elicit feelings and may cut off communication. Stating that it is never too late to start taking care of her health is a judgmental response, because it implies that the client has been negligent. Although it is true that most clients hate to have Pap smears, this statement ignores the client's current emotional needs.)

A 49-year-old client is admitted with a diagnosis of cervical cancer. As the nurse is obtaining her health history, she says, "I haven't had a Pap smear for more than 5 years. I probably wouldn't be in the hospital today if I'd had those tests more often." What is the nurse's most appropriate response? A. "Please tell me why you waited so long." B. "You feel as though you've neglected your health." C. "It's never too late to start taking care of yourself." D. "Most women hate to have Pap smears done, but they're really important."

D (The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.)

Which nursing process involves delegation and verbal discussion with the healthcare team? A. Planning B. Evaluation C. Assessment D. Implementation

B (For a high colonic enema, the fluid must extend higher in the colon. If the height of the enema fluid container above the anus is increased, the force and rate of flow also increase. 30 cm (12 inches) is too low for a cleansing enema. The heights of 51 cm (20 inches) and 66 cm (26 inches) are too high and may cause mucosal injury.)

A high cleansing enema is prescribed for a client. What is the maximum height at which the container of fluid should be held by the nurse when administering this enema? A. 30 cm (12 inches) B. 37 cm (15 inches) C. 51 cm (20 inches) D. 66 cm (26 inches)

D (Because clients have the right to know about their health status, the nurse should provide them with all relevant information. This is a therapeutic communication technique that enables clients to understand what is happening and what to expect. Asking for explanations, showing sympathy and asking personal questions of the client are nontherapeutic communication techniques.)

A nurse uses therapeutic communication techniques in order to achieve desired client outcomes. Which communication technique is a part of therapeutic communication? A. Asking for explanations B. Showing sympathy to the client C. Asking personal questions of the client D. Providing relevant information to the client

B (Evaluation includes assessing the client's response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the client's needs. Assessment entails collecting and reviewing objective and subjective data about the client's health status. Implementation includes performing specific actions designed to achieve the stated goals.)

A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied? A. Planning B. Evaluation C. Assessment D. Implementation

D (Administration of additional fluid when a client reports experiencing abdominal cramps adds to discomfort because of additional pressure. By clamping the tubing a few minutes, the nurse allows the cramps to subside, and the enema can be continued. Cramps are not a reason to discontinue the enema entirely; temporary clamping of the tubing usually relieves the cramps, and the procedure can be continued. Slowing the rate decreases pressure but does not reduce it entirely. Lowering the height of the container will reduce the flow of the solution, which will decrease pressure but not reduce it entirely.)

During administration of an enema, a client reports having intestinal cramps. What should the nurse do? A. Discontinue the procedure. B. Instill the fluid at a slower rate. C. Lower the height of the container. D. Stop the fluid until the cramps subside.

C (The lines of communication in a healthcare organization can be improved by appreciating and valuing each other's cultural perspectives, which balances strengths between the delegator and delegatee and improves client care outcomes. Considering all aspects of client care ensures that all of the client care needs are addressed. Selecting experienced nursing assistants as delegatees increases the chances of the delegatee to adapt to changing situations. Selecting a delegatee having similar strengths as that of the delegator may decrease the lines of communication because the delegatee might do the task of the delegator.)

How can the lines of communication be improved in a healthcare organization during the process of delegation? A. By considering all aspects of client care B. By selecting experienced nursing assistants as delegatees C. By appreciating and valuing each other's cultural perspectives D. By selecting a delegatee having similar strengths as that of the delegator

C (The licensed practical nurse provides tracheostomy care using sterile techniques. Developing a plan to avoid aspiration in a client with tracheostomy is done by the registered nurse. Assessing the client's condition after tracheostomy is done by the registered nurse. Teaching a client and caregiver about home tracheostomy care is done by the registered nurse.)

The registered nurse (RN) delegates a task to a licensed practical nurse (LPN) to take care of the client who underwent a tracheostomy. Which task should be performed by the LPN in this situation? A. Developing a plan to avoid aspiration B. Assessing the client's condition after tracheostomy C. Providing tracheostomy care using sterile techniques D. Teaching a client and caregiver about home tracheostomy care

D (In the acute phase, wound care is given by assessing the wound daily and adjusting the dressing if necessary according to the protocols. Assessing the extent and depth of burns is performed in the emergent phase. Providing a daily shower and removing the dead and contaminated tissue (debride) is performed in the emergent phase.)

Which wound care is given to a client with severe burn injuries during the acute phase? A. Assess extent and depth of burns B. Provide daily shower and wound care C. Remove dead and contaminated tissue D. Assess the wound daily and adjust the dressing