AQQ - Nursing Process
How can the nurse best describe heart failure to a client? a) A cardiac condition caused by inadequate circulating blood volume b) An acute state in which the pulmonary circulation pressure decreases c) An inability of the heart to pump blood in proportion to metabolic needs d) A chronic state in which the systolic blood pressure drops below 90 mm Hg
c) An inability of the heart to pump blood in proportion to metabolic needs As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, not decreased, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure usually does not drop.
The primary healthcare provider has prescribed an intravenous piggyback (IVPB) to be administered every 4 hours. The prescription is 1200 mg vancomycin, which must be added to 50 mL D5W after being diluted according the pharmacy's instructions. After the nurse dilutes the powdered medication with the correct amount of saline, the resulting solution contains 1 gram of drug per 3 mL. How much antibiotic solution should be added to the 50 mL of D5W? Record your answer using one decimal place.
3.6 The prescribed dose is 1200 mg. The available concentration of drug is 1 g/3 mL. The prescribed dose should first be converted to the available concentration. Then, use the dimensional analysis and/or ratio and proportion methods to determine the appropriate amount of medication to be added to 50 mL D 5W.
What does a community-based nurse do as a change agent? a) The nurse empowers clients and their families to creatively solve problems. b) The nurse works with clients to solve problems and helps clients identify an alternative care facility. c) The nurse helps clients gain the skills and knowledge needed to provide self-care. d) The nurse empowers clients to become instrumental in creating change within a health care agency. e) The nurse does not make decisions but rather helps clients reach decisions that are best for them.
As a change agent, the nurse empowers clients and families to creatively solve problems. As a change agent, the nurse works with clients to solve problems and helps them identify an alternative care facility. As a change agent, the nurse empowers clients to become instrumental in creating change within a health care agency. As an educator, the nurse helps clients gain the skills and knowledge needed for self-care. As a counselor, the nurse does not make decisions, but rather helps clients reach decisions that are best for them. a) The nurse empowers clients and their families to creatively solve problems. b) The nurse works with clients to solve problems and helps clients identify an alternative care facility. d) The nurse empowers clients to become instrumental in creating change within a health care agency.
A pregnant client asks the nurse for information regarding toxoplasmosis exposure during pregnancy. What information should the nurse teach this client? a) "Pork and beef should be cooked thoroughly." b) "Toxoplasmosis is a disease that is most prevalent in foreign countries." c) "Raw shellfish are intermediary hosts and should be avoided during pregnancy." d) "Salad dressings made with mayonnaise should be avoided during the summer months."
a) "Pork and beef should be cooked thoroughly." Thorough cooking of pork and beef before consumption helps prevent ingestion of the cyst stage of the Toxoplasma protozoa. Even though toxoplasmosis is more prevalent in foreign countries, it occurs in the United States and its prevention should be addressed. Raw shellfish are not related to toxoplasmosis. Salad dressings made with mayonnaise are not linked to toxoplasmosis.
What instructions should the nurse give to an adolescent to prevent sexually transmitted infections? a) "Remember to use condoms properly." b) "Abstain from any kind of sexual activity." c) "Make sure you are up-to-date with your vaccinations." d) "Have sexual contact only if you and your partner are monogamous." e) "Remember to have regular screenings for sexually transmitted disease."
a) "Remember to use condoms properly." c) "Make sure you are up-to-date with your vaccinations." d) "Have sexual contact only if you and your partner are monogamous." The safe use of condoms helps to avoid contact with body fluids and helps prevent sexually transmitted infections. Getting updated with vaccinations helps prevent vaccine-preventable sexually transmitted infections. Monogamous partners have a low risk of contracting sexually transmitted infections. Abstaining from sexual activity is not a practical approach. Regular screening for sexually transmitted infections helps to detect a disease at an early stage, but does not prevent contraction of the disease.
What nursing intervention should a nurse provide to a hospitalized individual in the identity versus role confusion stage? a) Provide the client with information about his or her treatment plan b) Choose creative ways to promote social participation c) Involve a client's partners or family members in the caring process d) Encourage the client to participate actively in the treatment procedure
a) Provide the client with information about his or her treatment plan During the identity versus role confusion or puberty stage, a nurse should help hospitalized adolescents deal with illness by helping them to make their own decisions about their treatment plan. During the generativity versus self-absorption and stagnation stage, the nurse should help the client socialize to foster a sense of fulfillment. If an individual under the intimacy versus isolation stage is admitted to the hospital, the nurse should involve the client's partners or family members in the caring process so that the client can have a positive support structure. During the industry versus inferiority stage, the nurse should encourage the client to participate actively in the treatment procedure.
A client hospitalized with heat stroke presents with a body temperature of 106° F and skin that is hot and dry. Which priority interventions should be provided to the client? a) Remove the client's clothing. b) Immerse the client in cold water. c) Keep the client from eating or drinking. d) Transfer the client to the critical care unit. e) Administer parenteral benzodiazepine to the client.
a) Remove the client's clothing. b) Immerse the client in cold water. Immediate priority care for heat stroke is to provide rapid cooling by removing the clothing and immersing the client in cold water to bring down the temperature. Refraining from giving food or liquids to the client is done before surgical procedures. Transferring the client to the critical care unit is to monitor complications such as multi-system organ dysfunction and is usually preferable when the client is stabilized. Parenteral benzodiazepine is given when the client experiences shivering during the cooling process.
What nursing actions are appropriate for an adolescent girl undergoing a pelvic examination? a) Teach the adolescent about hygiene, body function, and sexuality. b) Invite the adolescent's parent in the examination room. c) Postpone giving details about an exam as it may arouse fear in the adolescent. d) Encourage the discussion of safer sex practices. e) Display drawings, models, and equipment to help educate the adolescent.
a) Teach the adolescent about hygiene, body function, and sexuality. d) Encourage the discussion of safer sex practices. e) Display drawings, models, and equipment to help educate the adolescent. Adolescents are often apprehensive about a pelvic examination. During the pelvic examination, the nurse should give the adolescent information regarding hygiene, body functions, and sexuality. Drawings, models, and equipment should be displayed to better educate the adolescent. In addition, the nurse should discuss safer sex practices, sexually transmitted infection prevention, and the postponing of sexual activity until the adolescent feels emotionally ready. The adolescent's parents should not be invited without the adolescent's consent.
A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position? a) Supine b) Semi-Fowler c) Right side-lying d) Dorsal recumbent
c) Right side-lying The liver is on the right side of the body; the right side-lying position provides pressure at the needle insertion site and promotes hemostasis. The supine position does not provide pressure over the liver or promote hemostasis. The semi-Fowler position does not provide pressure over the liver or promote hemostasis. The dorsal recumbent position keeps the liver uppermost, thus no pressure is exerted to promote hemostasis.
A registered nurse is teaching a nursing student about malpractice insurance. Which statement by the nursing student requires correction? a) "Malpractice insurance provides for a defense when a nurse is alleged to have committed professional negligence or medical malpractice." b) "Most private insurance policies for nurses are primary policies that begin covering the nurse even before all hospital insurance coverage has been exhausted." c) "If both the employing institution and the nurse are sued, the nurse needs to notify his or her private insurance carrier of the lawsuit, even though the nurse has insurance through the hospital." d) "If both the hospital policy and the private policy are considered primary and the hospital loses as a result of the nurse's act, the hospital may sue the nurse's private insurer to recover its losses."
b) "Most private insurance policies for nurses are primary policies that begin covering the nurse even before all hospital insurance coverage has been exhausted." Most private insurance policies for nurses are excess policies that begin covering the nurse only after the hospital's insurance coverage has been exhausted. Malpractice insurance provides a defense when a nurse is in a lawsuit involving professional negligence or medical malpractice. If both the employing institution and the nurse are sued in a professional liability case, the nurse must notify his or her private insurance carrier of the lawsuit, even though the nurse has insurance through the hospital. If both the hospital policy and the private policy are considered primary and the hospital loses as a result of the nurse's act, the hospital may sue the nurse's private insurer to recover its losses.
A school-age child often steals money from home to buy chocolate. Upon being confronted by the parents, the child lies about stealing. The parents are worried that such behavior will steer the child toward criminal activities later in life. What is the best response from the nurse? a) "It is a normal behavior, and the child will grow out of it later." b) "Use admonition and ask the child to return the stolen money." c) "Catch the child in the act of stealing and ask for an explanation." d) "Inform all the family members and teachers about this behavior."
b) "Use admonition and ask the child to return the stolen money." The nurse should tell the parents that it is not necessary to attach any deep meaning to the child's stealing habits. With admonition and appropriate discipline the child will grow out of it. Simple punishment, like asking the child to return the stolen money, will help the child develop respect for other people's property. Stealing is not a normal behavior, and the nurse needs to instruct the parents that the behavior will be altered only if corrective measures are implemented. Catching the child in the act of stealing is not effective, because the child will refuse to accept responsibility for the act. Informing all the family members or teachers about this behavior will not help in curtailing this habit; rather, it will make the child feel ashamed.
A nurse notes that a client with dementia refuses to eat. Instead of informing the primary healthcare provider, the nurse threatens to force-feed the client, and proceeds to apply restraints in order to do so. What legal charges may be brought up against the nurse? a) Libel b) Assault c) Malpractice d) Invasion of privacy e) False imprisonment
b) Assault c) Malpractice e) False imprisonment In the given situation, the nurse threatens to force-feed the client, which is an example of assault. If the nurse fails to inform the primary healthcare provider regarding the problem faced when feeding the client, the nurse may be charged with malpractice for this action. Applying restraints to a client without the orders of the primary healthcare provider is considered false imprisonment.
Which method should the nurse refrain from using when measuring the blood pressure of a 2-year-old child? a) Choosing a pediatric stethoscope bell b) Basing the choice of cuff on its name c) Measuring the blood pressure 15 to 20 minutes after activity d) Placing the stethoscope softly on the child's antecubital fossa
b) Basing the choice of cuff on its name The nurse should refrain from choosing a cuff on the basis of the name (type) of the cuff. For instance, an infant cuff may be too small for some larger infants. The nurse should base the choice of cuff on size. Korotkoff sounds are difficult to hear in children because of their low frequency and amplitude. A pediatric stethoscope bell is often helpful. The nurse should allow at least 15 minutes for the child to recover from recent activity and to become less apprehensive. Placing the stethoscope too firmly on the antecubital fossa results in errors in auscultation, hence the stethoscope should be placed softly.
A client with scleroderma reports having difficulty chewing and swallowing. What should the nurse recommend to safely facilitate eating? a) Liquefy food in a blender. b) Eat a mechanical soft diet. c) Take frequent sips of water with meals. d) Use a local anesthetic mouthwash before eating.
b) Eat a mechanical soft diet. Scleroderma causes chronic hardening and shrinking of the connective tissues of any organ of the body, including the esophagus and face; a mechanical soft diet includes foods that limit the need to chew and are easier to swallow. Liquefied foods are difficult to swallow; esophageal peristalsis is decreased, and liquids are aspirated easily. Taking frequent sips of water with meals will not help; it is equally difficult to swallow solids and liquids, and aspiration may result. Using a local anesthetic mouthwash before eating is not necessary; oral pain is not associated with scleroderma.
An adolescent female suffering from severe cystic acne is placed on isotretinoin. What important facts should the nurse tell the client about isotretinoin? a) Inform the client to use vinyl helmet straps. b) Inform the client about the risk of teratogenicity. c) Inform the client that skin improvement may take time. d) Inform the client to scrub vigorously to remove blackheads. e) Inform the client to use abrasive cleansers to remove blackheads.
b) Inform the client about the risk of teratogenicity. c) Inform the client that skin improvement may take time. Even if an adolescent states that she is sexually inactive, the nurse should discuss viable birth control options with the client due to the risk of teratogenicity with isotretinoin. The client should be informed that it takes weeks to months for the skin to improve. Vinyl helmet straps may cause a mechanical irritation of acne leading to the development of lesions and therefore should not be used. Vigorous scrubbing may aggravate acne and cause damage to the skin and should be avoided. Using abrasive cleansers may cause skin trauma.
What should the nurse do to understand the nature of a client's pain? a) Cover the area of discomfort. b) Observe where the client locates the pain. c) Refrain from touching the area of tenderness. d) Note whether the pain radiates to any other part of the body. e) Instruct the client not to moves so as not to increase the pain.
b) Observe where the client locates the pain. d) Note whether the pain radiates to any other part of the body. To understand the nature of the client's pain, the nurse should notice where the client points when telling the nurse the location of the pain. The nurse should also observe whether the pain radiates to another part of the body or is localized. The nurse should inspect the area rather than cover it, and palpate the area of discomfort and tenderness to determine the severity of the pain. The nurse should note whether the pain increases while the client is moving or is relieved when the client is at rest.
A preterm neonate is receiving oxygen by way of an overhead hood. Which nursing interventions should the nurse implement to protect the infant under the oxygen hood? a) Offer fluid every 15 minutes to prevent dehydration b) Put a hat on the infant's head to prevent hypothermia d) Keep the oxygen concentration consistent to limit respiratory distress Remove the infant from the hood every 15 minutes to provide stimulation
b) Put a hat on the infant's head to prevent hypothermia Oxygen has a cooling effect, and the infant should be kept warm so metabolic activity and oxygen demands are not increased. Offering fluid every 15 minutes may produce fluid overload, which could in turn result in increased cardiac output; this is an undesirable outcome, especially for an infant with respiratory distress. Oxygen concentration is determined from blood gas levels and is changed accordingly. Removing the infant from the hood every 15 minutes will tire the infant and increase the need for oxygen.
A 2-month-old infant is admitted to the pediatric unit with a diagnosis of respiratory syncytial virus infection. The nurse plans to position the infant to improve the respiratory effort. What positions are best? a) Prone b) Semi-Fowler c) Trendelenburg d) Hyper-extended head e) Head in sniffing position
b) Semi-Fowler e) Head in sniffing position The semi-Fowler position allows gravity to pull the intestines away from the diaphragm, thereby improving respiration. When the infant's head is in a sniffing position the airway is shortened and respiratory function is improved. The prone position will not support respiratory function. The Trendelenburg position will put pressure on the diaphragm, restricting respirations. A hyperextended head restricts the airway.
An older adult with peripheral vascular disease has stopped smoking, and the client's children want to make the home environment safe. What should the home healthcare nurse emphasize when providing instructions? a) Observe for evidence of blurred vision b) Use measures that can prevent thermal injuries c) Reduce fluid intake to prevent peripheral edema d) Limit activities to reduce the workload on the heart
b) Use measures that can prevent thermal injuries The ability to perceive extremes in temperature is limited in the presence of peripheral vascular disease. Prevention of thermal injury through avoidance of hot and cold (e.g., hot water, heating pads, ice packs) is advised. Blurred vision is not associated with peripheral vascular disease. Limiting fluid intake may precipitate dehydration, increasing the risk of thrombophlebitis. Limiting fluids may be indicated if a client has heart failure, not peripheral vascular disease. Limiting activities to reduce the workload on the heart may be important for a client with heart failure, not with peripheral vascular disease.
What other name can the nurse use for vasopressin? a) Growth hormone b) Luteinizing hormone c) Antidiuretic hormone d) Thyroid-stimulating hormone
c) Antidiuretic hormone Antidiuretic hormone is also called vasopressin. Growth hormone can be called somatotropin. Luteinizing hormone is a gonadotropin. Thyroid-stimulating hormone can be called thyrotropin.
What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings? a) Monitoring vital signs b) Reassuring the client and family c) Assessing the level of consciousness d) Monitoring specific patient manifestations of stroke
c) Assessing the level of consciousness Assessing the level of consciousness is the priority nursing action in the client with stroke and who is transitioned from ED to other settings. Monitoring the vital signs, reassuring the client and family, and monitoring specific patient manifestations of stroke are ongoing nursing interventions.
A client with cyclothymic disorder with hypomanic symptoms is admitted to the psychiatric unit. The client has progressively lost weight and does not take the time to eat the provided food. How can the nurse best respond to this situation? a) By providing a tray in the client's room b) By assuring the client that food is deserved c) By ordering food that the client can hold and eat while moving around d) By pointing out that the client must replace the energy burned by eating
c) By ordering food that the client can hold and eat while moving around The client with hypomanic symptoms cannot tolerate sitting still long enough to eat an adequate meal; handheld foods will help meet the client's nutritional needs and do not require the client to sit down. This client will most likely ignore the tray. Unworthy feelings are related to a depressive, not manic, episode. It is unlikely that this client will understand or care about the need to replace energy with food.
A 2-year-old child who is hospitalized for repair of tetralogy of Fallot is seen squatting in the playroom. In response to this behavior, what should the nurse do? a) Administer oxygen through a mask. b) Call the respiratory therapist for a nebulizer treatment. c) Continue to observe the child if there are no other signs of distress. d) Notify the healthcare provide that the child's condition is deteriorating.
c) Continue to observe the child if there are no other signs of distress. Squatting is a physiologic adaptation for children with tetralogy of Fallot. By squatting, the child decreases the amount of arterial blood that is flowing to the extremities, which in turn decreases venous return to the heart and reduces preload. Oxygen is not indicated. The child has a heart, not a respiratory, problem, so a nebulizer treatment is not indicated. The child's condition has not deteriorated; squatting is a physiologic adaptation.
What should the nurse place in temporary shelters without running water that were created for disaster victims to use for toileting? a) Trash bags b) Bottled water c) Hand sanitizer d) Soap and paper towels
c) Hand sanitizer In the absence of water, hand sanitizer should be placed in the temporary shelters being used as bathrooms. The purpose of the hand sanitizer is to perform hand hygiene after toileting. Trash bags would not be appropriate since there is no running water in the shelters. Bottled water would be better used for drinking and not for hand hygiene. There is no running water, so soap and paper towels would not be appropriate.
Which instructions will be most beneficial for a diabetic client with renal disease? a) Recommend the client drink boiled water b) Suggest the client to go for a morning walk c) Instruct the client to check blood pressure regularly d) Contact the primary healthcare provider before taking ibuprofen e) Encourage the client to undergo a microalbuminuria test yearly
c) Instruct the client to check blood pressure regularly d) Contact the primary healthcare provider before taking ibuprofen e) Encourage the client to undergo a microalbuminuria test yearly High blood pressure affects normal kidney function. Clients with renal disease must monitor blood pressure, because increased blood pressure can damage the vessel walls of the kidneys, thereby causing kidney damage, leading to kidney failure. Thus clients with renal disease should be encouraged to check their blood pressure regularly. Drugs such as ibuprofen are potent nephrotoxic agents; therefore, the client must be advised to contact the primary healthcare provider before ingestion to avoid further complications. Diabetic clients should undertake a microalbuminuria test yearly to determine the risk of developing end-stage kidney disease. Drinking boiled water may reduce the risk of infections; however, this instruction is less beneficial when compared to the other interventions. Going for a walk will improve the overall health of the client, but it is not a specific intervention that improves kidney function.
A client who is recovering from a motor vehicle accident is discharged from the health care agency and transferred to an extended care facility for rehabilitation. What kind of health care service does this client receive? a) Preventive care b) Continuing care c) Restorative care d) Tertiary health care
c) Restorative care The client receives restorative care during rehabilitation. This care helps to restore the client to the fullest physical, mental, social, vocational, and economic potential. Immunization is an example of preventive care. The focus is on reducing and controlling risk factors for disease. Adult day care centers are an example of continuing care. The nurses in these centers provide continuity between care delivered in the home and the center. Tertiary health care is provided to acutely ill hospitalized clients who need comprehensive and specialized health care.
A nurse is working in a health care organization that has Magnet status. What specific responsibility does the nurse have in this organization? a) The nurse must follow best-practices for quality improvement. b) The nurse must use research-based practice to provide client care. c) The nurse must collect data for comparison against a national level. d) The nurse must refrain from taking independent actions during client care.
c) The nurse must collect data for comparison against a national level. The nurse in a Magnet health care organization must collect data on specific nursing-sensitive quality indicators or outcomes. This data must be compared with the national, state, or regional database to demonstrate quality care. The nurse must always follow evidence-based practice while providing client care. Best practice may not always be beneficial for the client. The nurse must use a problem-solving approach and combine research-based practice with client preferences and values. Nurses in Magnet health care organizations are encouraged to practice with a sense of empowerment and autonomy to deliver quality care.
A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection? a) Deltoid muscle b) Rectus femoris c) Vastus lateralis d) Gluteus maximus
c) Vastus lateralis The vastus lateralis is the most appropriate muscle for a newborn's intramuscular injection because it is well developed and there is little danger of nerve injury. The deltoid muscle is too small for a newborn's intramuscular injection. The rectus femoris muscle is not used; it is not as large as the vastus lateralis in a newborn. The sciatic nerve in the newborn is near the outer aspect of the gluteus maximus and might be injured if this site were used for an injection.
A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. What is the best response by the nurse? a) "That client is not on our unit. Thank you for calling." b) "The new privacy laws prevent me from providing any client information over the phone." c) "The client has requested that no information be given out. You'll need to call the client directly." d) "It is against the hospital's policy to provide you with any information."
d) "It is against the hospital's policy to provide you with any information." The response "It is against the hospital's policy to provide you with any information." is a factual statement, without indicating whether or not the client is in the hospital. The response "That client is not on our unit. Thank you for calling." is a lie and should be avoided. HIPAA (Canada: FOIPOP) laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly." implies that the client is admitted to the facility; this violates the client's request that no information should be shared with others.
A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse? a) "You will need to decrease your exercise." b) "An extra tablet will help your body use glucose correctly." c) "When taking medicine, your diet will not be affected by exercise." d) "No, but you should observe for signs of hypoglycemia while exercising."
d) "No, but you should observe for signs of hypoglycemia while exercising." Exercise improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia. Exercise should not be decreased because it improves glucose metabolism. An extra tablet probably will result in hypoglycemia because exercise alone improves glucose metabolism. Control of glucose metabolism is achieved through a balance of diet, exercise, and pharmacologic therapy.
A mother in the postpartum unit expresses concern that her 3-year-old daughter will be jealous of her new brother. What should the nurse suggest? a) Ignoring negative comments that the daughter makes about the baby b) Allowing the daughter to stay with her baby brother when the mother rests c) Explaining in simple terms why the mother must spend more time with the baby d) Bringing home a new baby doll for the daughter when her baby brother is brought home
d) Bringing home a new baby doll for the daughter when her baby brother is brought home Providing a doll for the child can encourage role-play with the new doll, which is an age-appropriate activity. The child can tend to the doll's needs while the parent performs similar activities and use this practice to progress to helping with the newborn. Ignoring the child's comments will reinforce insecurity and may promote acting-out behavior. The child is too young to be left alone with an infant. Telling the child that the mother must stay with the baby rather than with her may increase the child's feelings of jealousy.