ATI - Nurse Logic 2.0

A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching? 1/2 cup of white rice 1 slice of wheat bread 1 cup of 2% milk 3/4 cup of canned tomato juice

3/4 cup of canned tomato juice To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Question: Which of the following food or beverage selections by the client indicates a need for further teaching? Person of Focus: The client who has been taught about a 2,000 mg sodium-restricted diet Key Words: 2,000 mg sodium-restricted diet, selections, need for further teaching So, the question is asking which of nutritional selections is not appropriate for a client prescribed a 2,000 mg sodium-restricted diet. This is a negatively worded, traditional multiple choice item, which means there are four options. Of these options, three are accurate, called the distracters, and one is inaccurate, which is the key because the item is negatively worded. Because the question indicates there is only one correct answer, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 3/4 cup of canned tomato juice is correct. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. This beverage selection has approximately 820 mg of sodium; therefore, this food selection is not appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. This selection indicates that further teaching is required by the nurse.

A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider? Fine hand tremors Mild thirst Weight gain Slurred speech

Slurred speech To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is prescribed lithium (Eskalith). Question: Which of the following clinical findings should be immediately reported to the provider? Person of Focus: The client who is prescribed lithium Key Words: lithium, findings, immediately reported So, the question is asking which of clinical findings should be immediately reported to the provider. This is a positively worded, multiple choice item. The key word "immediately" in the question indicates this is a priority setting item, which means all four options are correct, but one takes priority over the others. In this item, all four actions are adverse effects of lithium and should be reported to the provider, but one of the findings needs to be reported immediately. Next you should review each option and determine which should be the priority action. Slurred speech is correct. Slurred speech is an early clinical finding associated with lithium toxicity and can precipitate the onset of seizures or coma. Using the safety and risk reduction priority setting framework, this finding jeopardizes the immediate physiological safety of the client and should be reported to the provider immediately.

A nurse in a pediatric provider's office is conducting telephone triage and receives a call from a client regarding her 4-day-old newborn who was circumcised 2 days ago. Listen to the audio clip and determine which of the following responses by the nurse is appropriate. (Click on the audio button to listen to the telephone conversation.) "Use warm water to soak the penis." "Apply petrolatum to the penis." "Bring the infant to the office for evaluation by the provider." "Do not attempt to remove it."

"Do not attempt to remove it." Scenario: A nurse in a pediatric provider's office is conducting telephone triage and receives a call from a client regarding her 4-day-old newborn's circumcision. Question: Listen to the audio clip and determine which of the following responses by the nurse is appropriate. Person of Focus: The 4-day-old newborn who was circumcised the day after birth Key Words: telephone triage, 4-day-old, circumcised the day after birth, audio clip, responses, appropriate So, the question is asking which of the responses by the nurse is appropriate to make to the mother of the newborn heard in the audio clip. This is an audio format item, which means you have to listen to the provided audio to determine the correct answer. There are four options, one which is correct, called the key, and three that are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. "Do not attempt to remove it" is correct. Yellow exudate covers the penis 24 hr after the circumcision and will persist for 2 to 3 days. This is an expected finding and should not be removed. The nurse should provide teaching to the client regarding circumcision care.

A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? A client who has a history of heart failure A client who has type 1 diabetes mellitus A client who is reporting pain associated with osteoarthritis of the knees A client who is having a nosebleed associated with hypertension

A client who is having a nosebleed associated with hypertension Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase - so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. A nose bleed, or epistaxis, is an acute condition requiring immediate intervention to prevent further blood loss. Additionally, this finding can be associated with a blood pressure that is above the expected reference range, indicating the need for further intervention. Based on the acute versus chronic priority setting framework, this client should be the nurse's priority.

A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client? Acupuncture is loosely regulated by the federal government. Acupuncture has been discredited by scientific research. Acupuncture is thought to be effective only as a placebo. Acupuncture has been proven to reduce pain and increase function.

Acupuncture has been proven to reduce pain and increase function. The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should include this information in discussions with the client. Acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies. Clinical research has also shown additional benefits of acupuncture, such as improving memory and orientation among clients who have certain types of dementia.

A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? Provide a toy doctor's kit to play with. Keep all syringes and needles out of sight until needed. Use an approach that is firm but direct. Allow the child to manipulate the medical equipment.

Allow the child to manipulate the medical equipment. The content of this question emphasizes the concept of client-centered care by implementing age-appropriate strategies to prepare a client for a procedure. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using age-appropriate strategies, nurses facilitate the provision of individualized, high-quality care. Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure.

A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first? Initiate a bladder training schedule. Administer solifenacin (Vesicare). Insert an indwelling urinary catheter. Perform intermittent catheterization.

Initiate a bladder training schedule. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Bladder retraining is a restorative care method used with clients who have urinary incontinence. Based on the least restrictive, least invasive priority setting framework, this is the first action the nurse should take.

A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol? Loss of color discrimination Nausea and vomiting Red-orange discoloration to body fluids Edema of feet and hands

Loss of color discrimination The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. The most commonly reported toxic reaction to normal therapeutic doses of ethambutol is ocular toxicity as evidenced by visual disturbances. Examples include changes of color vision (especially red and green) and loss of visual acuity. Treatment with ethambutol should be stopped immediately if ocular toxicity develops.

A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? Ensure all four side rails are up. Administer a prescribed sedative. Place the client in soft wrist restraints. Move the client to a room near the nurses' station.

Move the client to a room near the nurses' station. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using physical restraints. Physical restraints should only be used when the safety of the client, staff, or others is at risk. Moving the client to a room near the nurses' station allows for more frequent observation and promotes client safety. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than the other actions and should be the nurse's first action.

A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication? Urinary retention Rapid respirations Dilated pupils Diarrhea

Urinary retention In this item, you need nursing knowledge related to morphine to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of morphine. Morphine is an opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of well-being, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Urinary retention is an adverse effect of morphine. By increasing bladder sphincter and detrusor muscle tone and reducing awareness of bladder stimuli, morphine can cause urinary hesitancy, urinary retention, and urinary urgency.

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? Increased appetite Elevated temperature Bradycardia Drowsiness

Elevated temperature The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The identification of expected and unexpected findings associated with a client's diagnosis assists the nurse to distinguish possible unrelated complications the client might be experiencing, which indicates the need for further investigation. The specific focus on the client enhances the provision of safe, quality nursing care. An elevated temperature is a finding associated with acute alcohol delirium.

A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include? Medications will eliminate HIV in most clients. Adolescents are at a lower risk for developing HIV. Initial HIV symptoms are often similar to the flu. Using condoms ensures the prevention of HIV during sexual intercourse.

Initial HIV symptoms are often similar to the flu. The content of this question emphasizes the concept of client education by determining information that is appropriate to include in an educational program. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is appropriate for the nurse to include. HIV infection consists of three stages. The client typically experiences flu-like symptoms in the first or primary infection stage. Then, during the clinical latency stage, the client is asymptomatic. The final stage is characterized by the development of AIDS, which is when the client become symptomatic and has a severely compromised immune system.

A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions? Lithotomy Dorsal recumbent Prone Lateral recumbent

Lithotomy The content of this question emphasizes the concept of leadership by providing education to a newly licensed nurse. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. Nurses assume various types of leadership roles in the provision of client care, including delegator, coordinator, educator, advocate, and change agent. This is the appropriate position for the nurse to place the client. The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia. The nurse should drape the client appropriately to minimize exposure and embarrassment.

A nurse is caring for a client who has nausea and a prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule? Use a filter needle to administer the promethazine. Expel air bubbles back into the ampule. Set the ampule on a flat surface to withdraw the promethazine. Break the ampule toward the body.

Set the ampule on a flat surface to withdraw the promethazine. The content of this question emphasizes the concept of safety by appropriately preparing a medication from an ampule. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care. By adhering to protocols and procedures based on scientific literature, nurses are able to prevent injury and improve and create a safe environment for clients, self, and co-workers. This action by the nurse is appropriate. To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle.

A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter? Dorsal recumbent Orthopneic Side-lying ​Supine

Supine ​To answer this item, you need knowledge of inserting an indwelling urinary catheter on a male client. This item requires foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Indwelling urinary catheters are indicated in numerous situations, such as relief of bladder distension, strict measurement of urinary output, need for bladder irrigations, and surgery. A prescription from the provider is required for urethral catheterization. When preparing to implement this procedure, it is important to ensure client privacy by draping nonessential body parts and positioning the client for optimal visualization while still maintaining comfort. A male client should be positioned in the supine position for insertion of an indwelling urinary catheter. This position allows for optimal visualization, which reduces trauma and increases success of insertion.

A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate? 10 to15 lb 15 to 20 lb 25 to 35 lb 35 to 45 lb

25 to 35 lb To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. The recommended weight gain for women with an average BMI is 11.5 to 16 kg, or roughly 25 to 35 lb. This amount is sufficient to ensure that the fetus is adequately nourished.

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? A client who has peripheral vascular disease and reports numbness in the toes A client who has depression and is easily distracted A client who has Alzheimer's disease and is unable to complete activities of daily living A client who had abdominal surgery 10 days ago and reports feeling his incision pop

A client who had abdominal surgery 10 days ago and reports feeling his incision pop Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Wound dehiscence or evisceration most commonly occurs 3 to 11 days following surgery and can be caused by not splinting the surgical site when moving, forceful coughing, vomiting, or straining. Clients often report feeling the incision "pop," indicating either dehiscence or evisceration has occurred. Based on the acute versus chronic priority setting framework, the nurse should evaluate this client first.

A nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. Which of the following findings requires further intervention? Vesicular rash Respiratory rate 54/min Abdominal distension Heart rate142/min

Abdominal distension In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. Abdominal distension that is present at birth indicates a tumor or an abdominal wall defect, such as a ruptured viscus. This finding should be reported to the provider immediately and evaluated further.

A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following? Deontology Morality Principlism Advocacy

Advocacy In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. A legal and ethical responsibility of nurses is to protect the rights of clients and provide safe, quality nursing care. Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a person, group, or community. The nurse made the request to remove the playground equipment on behalf of and to benefit the children of the school. This is an example of advocacy.

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign? A preschooler with a hip spica cast who is being discharged today An infant scheduled for a surgical repair of a ventricular septal defect tomorrow A toddler with a fractured femur who has been in Bryant's traction for 5 days An adolescent who is 2 days postoperative following an appendectomy

An adolescent who is 2 days postoperative following an appendectomy The content of this question emphasizes the concept of leadership through the coordination of client care by making appropriate assignments. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. When making assignments, a leader should effectively communicate and have knowledge of the skill sets of team members in order to ensure clients receive care by the most appropriate person on the team. The care of an adolescent who is 2 days postoperative following an appendectomy requires postoperative care including education, infection prevention, and medications that require fundamental nursing skills and knowledge; therefore, it is appropriate to assign this client to the nurse who has floated from the labor and delivery unit.

A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? Administer an anticoagulant. Check the leg for warmth and edema. Apply elastic stockings. Promote bed rest and extremity elevation.

Check the leg for warmth and edema. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. If warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep-vein thrombosis. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? "I will only be on this medication 4 to 6 months because it can lead to physical dependence." "I can have 1 to 2 alcoholic beverages each week." "I will need to stop taking Xanax two weeks before I can begin taking this medication." "I can have 6 to 8 ounces of grapefruit juice each day."

"I can have 1 to 2 alcoholic beverages each week." The content of this question emphasizes the concept of client education by determining which statement by the client indicates effectiveness of the teaching. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. Buspirone is an anxiolytic medication used to treat anxiety, but is different from benzodiazepines because of the fact that it is not a CNS depressant. Because of this, buspirone does not interfere with CNS depressants, such as benzodiazepines, alcohol, or barbiturates, and it is acceptable to have 1 to 2 alcoholic beverages each week. This statement by the client is true and indicates an understanding of the teaching.

A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching? "I will have my husband wear a condom during intercourse." "I will check my temperature every 4 hours." "I will wipe from front to back after bowel movements." "I will notify my doctor if my baby moves fewer than 4 times in the 2 hours following each meal."

"I will have my husband wear a condom during intercourse." The content of this question emphasizes the concept of client education by determining the need for additional teaching. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. The client who has experienced a premature rupture of membranes should not engage in sexual activity or insert anything in the vagina because of the increased risk for infection. This statement by the client indicates a need for additional teaching.

A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching? "I will be sure to use the nebulizer four times per day." "I can't use my cromolyn nebulizer for a sudden asthma attack." "It will be several weeks before I notice an improvement in my asthma." "I will use my cromolyn nebulizer before using my albuterol inhaler."

"I will use my cromolyn nebulizer before using my albuterol inhaler." In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client needs further teaching. You will learn more about negatively worded items in Module 4.This item requires foundational thinking because you have to recall knowledge to determine which of the client's statements about cromolyn was false. "I will use my cromolyn nebulizer before using my albuterol inhaler" is not a true statement and indicates a need for further teaching. Cromolyn is an inhalation agent used to reduce bronchial inflammation and for the prophylactic management of mild to moderate asthma. Education to the client about the medication should specifically include that it is not effective for quick relief, and that when administered routinely on a set schedule, both the frequency and intensity of asthma attacks is decreased. However, it is also important to note that cromolyn can reduce exercise-induced bronchospasms when administered 15 min prior to anticipated exertions. When both cromolyn and albuterol are prescribed, albuterol should be inhaled first to open the airways because is a bronchodilator. After waiting a few minutes, the cromolyn can then be inhaled and will reach further into the lungs because of the dilatory effects of albuterol.

A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements by the client indicates a need for further teaching? "I'll make sure that the medication container is kept tightly sealed." "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." "I'll keep my pills in the medicine cabinet when I'm home." "I'll go to the emergency room if my chest pain doesn't go away."

"I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." In this item, you need nursing knowledge related to the proper administration and storage of nitroglycerin. Based on an understanding of this information, you can identify which option describes a statement by the patient that does not reflect accurate understanding of the medication. This is a negatively worded item that asks you to select the option that indicates the patient needs further teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the administration and storage of nitroglycerin. This statement by the client indicates a need for further teaching. Buying nitroglycerin in bulk quantities is not a safe practice. The chemical instability of the medication allows it to lose effectiveness over time. While some nitroglycerin tablets have a shelf life of 24 months, NitroQuick retains its effectiveness for only 8 to 10 months. Because of the shortened shelf life, the client should not buy the medication in bulk quantities, and the client should be instructed to date the bottle when it is first opened.

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching? "It is necessary to have written consent for invasive procedures." "Implied consent is appropriate for some aspects of nursing care." "It is the responsibility of the provider to obtain express consent." "Informed consent should be obtained separately for each surgical procedure."

"It is the responsibility of the provider to obtain express consent." The content of this question emphasizes the concept of professionalism by ensuring understanding of the legal concept of consent. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching.

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate? "I know this must be difficult, but your mother will calm down soon." ​"Let's discuss some strategies you can use when this happens again." "Individuals near death are ready to let go toward the end." "Have you determined why she is crying and saying she is ready to die?"

"Let's discuss some strategies you can use when this happens again." The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication assists the nurse to develop client relationships that foster trust and respect. This response by the nurse offers to provide information, which can reduce anxiety and enhance decision-making. This response by the nurse creates a safe and secure environment, fosters trust and respect, and is appropriate.

A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate? "Clients having this surgery are always scared." "Why have you changed your mind about the surgery?" "You shouldn't worry, everything will be fine." "Tell me more about your concerns."

"Tell me more about your concerns." In this item, you need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Giving a general lead encourages the client to openly share feelings and concerns in a non-threatening environment, which will assist in establishing a meaningful nurse-client relationship. This response by the nurse is appropriate and fosters the nurse-client relationship.

A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). Which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy? 0.25 mEq/L 0.75 mEq/L 1.5 mEq/L 2.25 mEq/L

0.75 mEq/L To answer this item, you need knowledge of therapeutic serum lithium level levels. Based on your understanding of this information, you can select the option with the serum lithium level appropriate for maintenance therapy. This item requires foundational thinking because you have to recall knowledge of therapeutic serum lithium levels. Lithium is a mood-stabilizing medication used in the treatment of bipolar I acute and recurrent manic and depressive episodes. To achieve a therapeutic range, give 300 mg to 600 mg of lithium during the active phase. The therapeutic serum lithium level is between 0.8 mEq/L and 1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are prescribed lithium for long-term therapy. Because small increments of dosage separate therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for maintenance therapy.

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions? A client who has rubella A client who has measles A client who has hepatitis A A client who has Rocky Mountain spotted fever

A client who has rubella To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Rubella is transmitted through the nasopharyngeal secretions of the infected person, and is also found in blood, stool, and urine. Because droplets associated with the illness are larger than 5 mcg, the Centers for Disease Control and Prevention recommends placing clients who are diagnosed with rubella on droplet precautions. Droplet precautions include placing the client either in a private room or with other clients who have the same disease, as well as using of a mask or respirator when providing care. This client should be placed on droplet precautions.

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the client's code status to do-not-resuscitate (DNR)? A written prescription from the provider Signed documentation from the client Family support of the decision Admission to hospice for palliative care

A written prescription from the provider In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. A DNR is typically instituted at the request of a client or family member and should be a written order instead of a verbal prescription. Until a DNR prescription exists, every attempt to revive the client should be made in the event of respiratory or cardiac arrest. A written prescription from the provider is necessary to legally change the client's code status to a DNR.

A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality? Placement of computer systems in restricted areas Installation of firewall software on each computer Ability of staff to access electronic health records of clients throughout the facility Occurrence of an automatic log-off after a period of inactivity

Ability of staff to access electronic health records of clients throughout the facility The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology. In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is not appropriate and can result in a violation of client confidentiality. The ability of staff to access electronic health records of clients throughout the facility allows for viewing confidential information on clients the staff might not directly be involved in the care of. The majority of staff should only be allowed to access the electronic health records of clients on the unit where he or she works.

A nurse administrator is reviewing policies and procedures of the facility she works in to ensure confidentiality requirements are being met. Which of the following indicates that intervention is needed to prevent the release of confidential client information? Requiring client information be sent to providers using presaved numbers on speed dial of the fax machine Assigning staff members on each shift the same password for accessing medical records Allowing nurses to complete electronic documentation on a client while at the client's bedside Discussing a client's financial hardship at an interdisciplinary team meeting

Assigning staff members on each shift the same password for accessing medical records In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to determine the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. Each staff member should have a personal password that is not shared with others and is used to enter and sign-off of computerized records. Individuals caring for a client should be the only ones able to access client records. If all staff members on each shift have the same password, limitations exist in tracking who is accessing those records, increasing the possibility that someone not involved in the care of a client could access records out of curiosity. This procedure is not appropriate and requires intervention to prevent the release of confidential information.

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? Initiate oxygen therapy. Encourage an increase in oral fluids. Provide room humidification. Assist client to cough effectively.

Assist client to cough effectively. Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Assisting the client to cough effectively opens the airway by removing secretions. Based on the ABC priority setting framework, this is the first action the nurse should take because a clear airway is necessary for oxygen exchange to occur.

A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles? Justice Autonomy Veracity Fidelity

Autonomy The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Autonomy is respecting the client's right to make personal health care decisions, whether or not the nurse believes those decisions are in the best interest of the client. This is the ethical principle the nurse is illustrating by making the referral as requested.

A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? To the left To the right Away from the body Toward the body

Away from the body To answer this item, you need knowledge of sterile procedures. This item required foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination. During such procedures, any sterile item that comes into contact with an unsterile object is considered contaminated. To prevent contamination of the sterile field, nurses follow certain steps when opening sterile packages and creating a sterile field. Opening the sterile package away from the body first allows a nurse to open the remaining flaps without reaching over the sterile field, which could result in contamination. This is the appropriate direction to open the sterile package.

A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following? Celecoxib is contraindicated in clients taking valproic acid. Celecoxib is contraindicated in older adults. Celecoxib is contraindicated in clients with a seizure disorder. Celecoxib is contraindicated in clients with an allergy to sulfonamide.

Celecoxib is contraindicated in clients with an allergy to sulfonamide. The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore, celecoxib is contraindicated in clients who have an allergy to sulfa.

A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit? Obtain an arterial pH level. Check the heart rate and blood pressure. Insert an indwelling catheter. Collect a serum BUN and creatinine.

Check the heart rate and blood pressure. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. An increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit. Using the least restrictive, least invasive priority setting framework, this action is less invasive than the other actions and should be the nurse's first action.

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? - Isopropyl alcohol - Chlorhexidine gluconate (Hibiclens) - Chlorine (bleach) - Iodophor

Chlorine (bleach) This item requires foundational thinking because you have to recall knowledge specific to disinfectants that are effective against bloodborne pathogens. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. Chlorine is a disinfectant that is effective against bacteria, tuberculosis, spores, fungi, and viruses, and is specifically recommended for cleaning blood spills. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Chlorine should be used to clean the spill.

A nurse is caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? Establishing a sense of achievement Contributing to society Creating meaningful social relationships Enhancing self-confidence

Creating meaningful social relationships Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The third level of Maslow's Hierarchy of Needs includes love, affection, and social relationships in fulfilling love and belonging needs. Social relationships are a component of friendship, which would be included in the third level of Maslow's Hierarchy of Needs. Based on Maslow's Hierarchy of Needs, this is the client's priority need.

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching? Cue the client by providing picture cards that portray common needs. Increase the volume of the voice when speaking to the client. Encourage the client to limit hand gestures when communicating. Vary the use of phrases and terminology in discussions.

Cue the client by providing picture cards that portray common needs. The content of this question emphasizes the concept of client education by determining the appropriate communication strategy to include in teaching to the caregiver of a client who has aphasia. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. Appropriate communication techniques will enhance the caregiver's ability to care for the client, as well as the client's self-expression, thereby ensuring the client's needs are met. Clients who have aphasia have difficulty expressing themselves and understanding what is being said. Using picture cards that portray common needs provides cues for the client and enhances communication. The nurse should include this communication strategy in the teaching.

A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness? Rapid weight gain Tar-colored stools Lethargy Dark urine

Dark urine In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree. The biliary tree begins as many small ducts that join together into one main common bile duct, similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to the small intestine where bacteria break it down into urobilinogen to be excreted in the feces. Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the liver and being excreted in the urine. The nurse should teach the parent that dark urine is a clinical manifestation associated with the illness.

A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? - Spongy gums that are receding - Fissures at eyelid corners - Easily plucked hair - Deep reddish-colored tongue

Deep reddish-colored tongue In this item, you need nursing knowledge of clinical findings that are associated with healthy nutrition. Based on an understanding of this information, you can identify which option describes an expected finding in clients who are properly nourished. This item requires foundational thinking because you only need to recall knowledge related to expected clinical findings. Deep reddish-colored tongue is suggestive of a healthy nutritional status. The tongue should be a healthy pink to a deep, reddish color with surface papillae present, without swelling or lesions.

A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective? Self-reporting the ability to perform the procedure Answering appropriately when questioned orally Responding accurately on a written examination Demonstrating independent performance of the procedure

Demonstrating independent performance of the procedure The content of this question emphasizes the concept of client education by determining the best indicator of teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This is the best indicator of teaching effectiveness. Return demonstration is the best evaluation tool for psychomotor learning, which is the acquisition of knowledge or skills that integrate mental and muscular activity.

A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take? Administer epinephrine (Adrenaline). Elevate the lower extremities. Determine respiratory status. Apply oxygen via non-rebreather mask.

Determine respiratory status. The content of this question emphasizes the concept of priority setting by determining priority nursing action for a client experiencing an allergic reaction. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This item can be answered using both nursing process and the ABC priority setting framework. The client is experiencing angioedema, indicating the possibility of an anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status.

A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action? Inform the nurse manager. Determine the client's condition. Notify the provider. Complete an incident report.

Determine the client's condition. The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is the first action the nurse should take when discovering a medication error. The client is the immediate concern, and determining his condition is crucial to the delivery of safe, effective care.

A nurse is collecting data on four clients. Which of following is the highest priority finding by the nurse? Malaise Anorexia Headache Diarrhea

Diarrhea Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining circulation is the nurse's priority concern. Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume. Based on this knowledge and using the ABC priority setting framework, this is the highest priority finding by the nurse.

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? (Select all that apply.) Dietician Physical therapist Hospice nurse Social worker Respiratory therapist

Dietician Physical therapist Social worker Dieticians have expertise related to dietary contributions to maintaining health and treating disease and can offer the team suggestions that promote wound healing and muscle repair. The dietician should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation. Physical therapists have expertise related to the musculoskeletal system and implements therapeutic treatments that will rebuild and improve strength, teach new skills, and regain mobility. The physical therapist should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation. Social workers have expertise in working with clients and families to resolve issues that arise due to health problems and can link the client with community resources, assist with developing the discharge plan, and resolve conflict. The social worker should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation.

A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention? Painful swallowing Hoarse voice Difficulty breathing Blood-tinged sputum

Difficulty breathing The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding can lead to hypoxia; therefore, immediate intervention is warranted. The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication.

A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? Lithium carbonate 0.8 mEq/L Digoxin 3.0 ng/mL Peak serum gentamicin 6 mcg/mL Magnesium sulfate 4 mEq/L

Digoxin 3.0 ng/mL Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients get priority because of needs that threaten their survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option poses the greatest risk to the client. This digoxin level is above the expected reference range and indicates digoxin toxicity. Based on the unstable versus stable priority setting framework and nursing knowledge, this lab value is the priority and should be immediately reported to the provider.

A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider? Silver-colored striae Unilateral nipple inversion present since menarche Dimpling of the tissue in the upper outer quadrant Visible symmetrical venous patterns

Dimpling of the tissue in the upper outer quadrant In this item, you need nursing knowledge related to data collection of the breasts and knowledge of deviations from the expected that are indicative of cancer. Based on an understanding of these concepts, you can identify which option describes a finding that is not within the expected range and can indicate a cancerous lesion. This item requires foundational thinking because you have to identify which finding is outside the expected range. Dimpling of the tissue in the upper outer quadrant should be considered an unexpected finding and reported to the provider. In fact, dimpling that is noted anywhere within the breast tissue should be reported. Dimpling makes the tissue appear retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor. This variation of the breast tissue is consistent with breast cancer.

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice? Assign a security guard to stay at the client's door. Request a prescription from the provider for soft restraints. Discuss the risks associated with leaving with the client. Remove the telephone from the client's room.

Discuss the risks associated with leaving with the client. The content of this question emphasizes the concept of professionalism by determining the legal actions of the nurse when a client leaves a facility against medical advice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Discussing the risks associated with leaving the facility against medical advice with the client is a priority concern. The client should be made aware of potential negative outcomes that could occur if he chooses to leave the facility prior to physician-prescribed discharge.

A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor? Faxing laboratory results to a client's provider Discussing changes in a client's plan of care with his friend who is a nurse on another unit Describing a client's level of independence to the case manager arranging home health services Remaining in the room with the client while he reviews his own medical records

Discussing changes in a client's plan of care with his friend who is a nurse on another unit In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention by the nurse preceptor is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to interpret the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. A nurse discussing changes in a client's plan of care with another nurse on another unit is a breach of confidentiality. Client information can only be shared with other health care professionals involved in that client's care. The nurse on the other unit should be directed to the client to request information about changes in the client's plan of care. This action is not appropriate and requires intervention by the nurse preceptor.

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication? Hyperkalemia Severe diarrhea Atelectasis Excessive vomiting

Excessive vomiting The content of this question emphasizes the concept of safety through the identification of a specific manifestation that can lead to metabolic alkalosis. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating potential complications, nurses are better able to predict a needed intervention, which assists in preventing or minimizing physical or psychological harm to the client. Metabolic alkalosis is a potential complication of excessive vomiting because of the loss of acid from the body.

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following? Facial edema Urinary frequency Acid indigestion Breast leakage

Facial edema The content of this question emphasizes the concept of client education by determining manifestations the client should be taught to immediately report to the provider. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for the client to be taught symptoms that should be immediately reported to the provider to prevent or reduce potential harm to herself or the fetus. Facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider.

A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? Administer medications with meals when possible. Ensure client understanding of medication's effects. Determine the client's ability to self-administer medications. Have the client position the head with the chin down while swallowing.

Have the client position the head with the chin down while swallowing. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Clients are at risk for aspiration following a CVA, and having the client position the head with the chin down while swallowing reduces this risk. Based on the safety and risk reduction priority setting framework, this should be the nurse's priority action. Preventing aspiration is further supported as the priority by the ABC priority setting framework.

A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client? Raising her voice level when speaking to the client Asking the client open-ended questions Clarifying client statements with the family as needed Having the client use eye blinks to indicate yes or no

Having the client use eye blinks to indicate yes or no The content of this question emphasizes the concept of client-centered care by identifying the appropriate technique to communicate with a client who is diagnosed with aphasia. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Having a client who has aphasia use eye blinks to indicate yes or no is an appropriate action by the nurse. This action reduces anxiety of the client, allows for appropriate communication, and reduces the risk for miscommunication.

A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication? Hypothermia Polyuria Headache Seizures

Headache To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Lumbar punctures are performed to withdraw cerebrospinal fluid found in the subarachnoid space for analysis. This is accomplished by inserting a needle into the lumbar subarachnoid space, typically between the third and fourth or fourth and fifth lumbar vertebrae. After the cerebrospinal fluid specimen has been removed, it is not uncommon for leakage of cerebrospinal fluid to continue at the puncture site. The leakage of cerebrospinal fluid leads to insufficient cerebrospinal fluid in the brain, which causes an inability to maintain appropriate mechanical stabilization of the brain. A headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture that results from cerebrospinal fluid leakage at the puncture site. These headaches are managed primarily with analgesics, hydration, and bed rest.

A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? Hypomagnesemia Hyperglycemia Hyponatremia Hyperkalemia

Hyperglycemia In this item, you need nursing knowledge of dexamethasone to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of dexamethasone. Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. Hyperglycemia, an elevated blood glucose level, is an adverse effect of dexamethasone. Both hyperglycemia and glycosuria can be manifested in clients who are taking dexamethasone because of its effect on the production and use of glucose.

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? Tachycardia Sternal retractions Hypoglycemia Hypothermia

Hypoglycemia The content of this question emphasizes the concept of safety through the recognition of a potential adverse effect that can result in physical harm. Safety in nursing practice is the minimization of risk factors that can cause harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.

A newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are in which of the following categories during a disaster? Immediate Delayed Minimal Expectant

Immediate Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client with injuries that are severe, but has the potential to survive with treatment. Clients assigned to the immediate triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received. Based on the survival potential priority setting framework, the nurse should provide priority care to clients in this category.

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene? Including in a client's nurses' note that an incident report was completed after a medication error Drawing horizontal lines through blank spaces left in the nurses' notes followed by a signature Refusing to chart the vital signs taken by another nurse on a client's graphic flow sheet Documenting the provider was contacted to clarify a questionable prescription

Including in a client's nurses' note that an incident report was completed after a medication error The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is not an appropriate action and requires intervention from the nurse preceptor. Incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often used in quality improvement programs for the facility. While an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record.

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? Pupil dilation Ataxia Lethargy Bradycardia

Lethargy The content of this question emphasizes the concept of safety through the identification of an initial manifestation of increased ICP. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating potential complications, nurses are better able to predict a needed intervention, which assists in preventing or minimizing physical or psychological harm to the client. Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in the level of consciousness, such as restlessness, irritability, and disorientation, lethargy is the first sign of increased ICP.

A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills? - Living wills require a written prescription from the provider to be legal. - Living wills allow the client to designate a health care proxy. - Living wills ensure hospitals provide emergency care regardless of health coverage. - Living wills detail treatment wishes of the client in the event of terminal illness.

Living wills detail treatment wishes of the client in the event of terminal illness. In this item, you need knowledge of advance directives. Based on this information, you can select the option that would be appropriate to include when teaching staff about living wills. This is a foundational item because you have to recall knowledge specific to the content and purpose of a living will. Advance directives include both living wills and durable powers of attorney for health care. The living will details treatment wishes of the client in the event of terminal illness or persistent vegetative state. This information is accurate and should be included in the teaching about living wills.

A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action? Providing pain control Preventing hemorrhage Maintaining a patent airway Ensuring adequate fluid intake

Maintaining a patent airway Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating that oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway is the nurse's priority action for a client who is in the immediate postoperative period following a tracheotomy. An airway obstruction is a potential complication for clients following head and neck surgery secondary to production of mucus and need for suctioning. Based on this knowledge and using the ABC priority setting framework, the nurse's priority action is to maintain a patent airway.

A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at an increased risk for hypokalemia? Nephrostomy tube to drainage bag Indwelling catheter to gravity Chest tube to water seal NG tube to suction

NG tube to suction To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. Hypokalemia refers to a depletion of potassium and can result from a reduction in total potassium stores or from a temporary shift of extracellular potassium into the cell. Reductions in total potassium are caused by medications, such as diuretics, digitalis, and corticosteroids; Cushing's syndrome; diarrhea; vomiting; and wound drainage among others. Reductions in extracellular potassium caused by potassium shifting back into cells result from alkalosis, hyperinsulinism, total parenteral nutrition, and water intoxication among others. Intestinal suctioning through an NG tube results in the loss of gastric fluids. Potassium exists in large amounts in the GI fluids and is lost when gastric fluids are lost. This client is at an increased risk for hypokalemia.

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? Obtain an ECG. Administer oral potassium. Encourage potassium-rich foods. Monitor I & O.

Obtain an ECG. Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range. According to Maslow's Hierarchy of Needs priority setting framework, physiological needs, such as adequate cardiac functioning, receive highest priority. This action is further supported by the ABC priority setting framework due to the impact of cardiac function on circulation.

A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? - Determining the client's respiratory rate - Measuring the client's chest diameter - Obtaining the client's level of oxygen saturation - Checking the client's depth of respirations

Obtaining the client's level of oxygen saturation In this item, you need nursing knowledge related to what the term tissue perfusion means. Based on an understanding of this, you can identify which of the following findings is an indicator of adequate tissue perfusion. This item requires foundational thinking because you only need to identify which of the following options describes a technique for measuring tissue perfusion. Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Obtaining the client's level of oxygen saturation level is an appropriate technique of measuring perfusion. Oxygen saturation measures the percent of hemoglobin bound with oxygen that is being perfused through the arteries and into the tissues.

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile? Prospective audit Outcome audit Process audit Structure audit

Outcome audit The content of this question emphasizes the concept of quality improvement by selecting the appropriate audit to conduct when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile. The primary goal of quality improvement is developing and implementing a plan to improve health care services and better meet the needs of clients. To accomplish this goal it is necessary to recognize client and facility issues that impact the provision of safe, quality care, as well as identify gaps between current practices and best practices. Audits are a process of measuring the quality of delivered care so better practices can be developed and implemented when needed. An outcome audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes. This type of audit is appropriate to use when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile.

A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin? - Cyanosis - Jaundice - Erythema - Pallor

Pallor ​In this item, you need nursing knowledge related to oxyhemoglobin and its effect on skin color. Based on an understanding of these two concepts, you can identify indicators of decreased oxyhemoglobin. This item requires critical thinking because you have to analyze the findings in relation to the expected color of the skin when there is a decreased level of oxyhemoglobin in the blood. Oxyhemoglobin is the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it. In clients who have anemia, the RBCs are reduced, by function or in number, to the point that peripheral tissues are not receiving adequate oxygen because of a decreased amount of circulating oxyhemoglobin. The reduced oxygen supply to the tissues causes changes to the client's skin color. Pallor is caused by a reduced amount of oxyhemoglobin. Pallor is a decrease in the coloring of the peripheral tissues that is caused by an overall reduction in the blood flow or by a decrease in the number of RBCs that contain oxyhemoglobin, which reduces the visibility of oxyhemoglobin.

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? Place O2 at 2 L per nasal canula on the client. Place the client in the orthopneic position. Perform chest percussion. Perform nasotracheal suctioning.

Place the client in the orthopneic position. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort. Based on the least restrictive, least invasive priority setting framework, this should be the first action the nurse takes.

A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? Place the infant in a supine position when sleeping. Place the infant on a firm mattress when sleeping. Avoid covering the infant with loose bedding while sleeping. Avoid leaving stuffed animals in the crib with the sleeping infant.

Place the infant in a supine position when sleeping. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Evidence-based practice and current recommendations of the American Academy of Pediatrics include positioning the infant supine while sleeping. This intervention has had the greatest impact on reducing the occurrence of SIDS. Using the safety and risk reduction priority setting framework and nursing knowledge, this is the priority information to include in the discharge teaching.

A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention? Cholesterol 220 mg/dL Platelets 95,000 mm3 BUN 20 mg/dL Potassium 3.5 mEq/L

Platelets 95,000 mm3 Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten their survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option poses the greatest risk to the client. This platelet level is below the expected reference range and indicates the client is at risk for bleeding. Based on the stable versus unstable priority setting framework and nursing knowledge, the client with this laboratory value requires immediate intervention.

A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention? Blood glucose 150 mg/dL Potassium 2.5 mEq/L Total protein 5.2 g/dL Urine specific gravity 1.040

Potassium 2.5 mEq/L The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding requires immediate intervention. A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmias or cardiac arrest. Because this level is life threatening, it is the priority at this time.

A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program? Watch a video discussing healthy meal preparation. Prepare a healthy meal to serve at the end of class. Read pamphlets about preparing a healthy meal. Discuss healthy meal preparation as a class.

Prepare a healthy meal to serve at the end of class. In this item, you need knowledge of learning styles in order to determine strategies that enhance learning for each of the styles. This item requires critical thinking because you need to recall knowledge of each of the learning styles in order to analyze the options and determine which strategy is appropriate to enhance the transfer of knowledge for tactile learners. Learning styles are simply different approaches to learning. For learning to be effective, it is important to identify and recognize learning styles of the clients being taught. Tactile learners learn best by touching and doing; therefore, having the participants prepare a healthy meal to serve at the end of class is a learning strategy appropriate for tactile learners.

A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal? Support the client's relationship with his caregivers. Encourage the client to express his feelings. Determine who is responsible for the abuse. Protect the client from further abuse.

Protect the client from further abuse. The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. Protecting the client from further abuse should be the nurse's priority goal, as failure to do so can result in additional harm to the client. Maslow's Hierarchy of Needs states that if there is not a physiological need, then safety needs must be considered first. Because the client has been hospitalized for 3 days, physiological needs have most likely been taken care of; therefore, the nurse should act to keep the client safe from harm.

A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? Chill formula prior to administration. Verify feeding tube placement. Reduce the rate of the feedings. Place the client supine during feedings.

Reduce the rate of the feedings. In this item, you need nursing knowledge of how to administer enteral tube feedings, complications of enteral tube feedings, and appropriate nursing actions in the event of those complications. Based on an understanding of these concepts, you can identify which option describes an intervention the nurse should implement for a client who is receiving enteral tube feedings and has diarrhea. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Reducing the rate of feedings is an appropriate action by the nurse to prevent diarrhea after subsequent feedings. A client receiving intermittent enteral tube feedings can experience diarrhea because of the administration of hyperosmolar enteral feedings. To prevent this, administration should be slowed or switched to continuous enteral feedings.

A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion? Reduced bleeding time Decreased plasma globulins Improved activity tolerance Increased immune functioning

Reduced bleeding time The content of this question emphasizes the concept of safety through an understanding of the purpose of a platelet transfusion. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating expected therapeutic outcomes, nurses are better able to evaluate treatment effectiveness, which is essential in preventing or minimizing physical or psychological harm to the client. Platelets are responsible for triggering the process of blood clotting. In response to intrinsic factors, such as abnormal blood, or extrinsic factors, such as inflammation or damage to blood cells because of trauma, platelets form platelet plugs. The formation of a platelet plug then triggers the more formal process of blood coagulation. Clients who have leukemia are prone to bleeding because of low platelet counts and should, therefore, experience a reduced bleeding time as a result of a transfusion of platelets.

A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority? Hematocrit 32% WBC 16/mm3 Slurred speech Yellowed sclerae

Slurred speech To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. Sickle cell anemia is characterized by the partial or complete replacement of mature hemoglobin with sickled hemoglobin. The sickled shape of cells can block or reduce the flow of blood through blood vessels, resulting in complications. Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral infarction, which leads to neurological impairment. Because a CVA threatens the life of the client, this is highest priority finding.

A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication? Speech pathologist Occupational therapist Social worker Respiratory therapist

Speech pathologist The content of this question emphasizes the concept of the interdisciplinary collaboration by recognizing the health care professional who should be present at the next interdisciplinary team meeting for a client who is experiencing difficulty swallowing. Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making, as well as achieve continuity of care and positive client outcomes. A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy. The speech pathologist should attend the next meeting to address difficulty swallowing in a client who has had a cerebrovascular accident.

A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis? Tuberculin test Chest x-ray Enzyme-linked immunoassay (ELISA) test Sputum culture for acid-fast bacillus

Sputum culture for acid-fast bacillus In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis, which is an airborne organism. Once infected, the bacteria multiply freely after reaching the bronchi or alveoli. Typically, acquired immunity protects individuals from attaining active tuberculosis. Infection is most common among those who are immunocompromised and those who have been in repeated, close contact with someone who has an undiagnosed case of active tuberculosis. The lungs are primarily involved, but the infection can spread to other organs. Symptoms of pulmonary tuberculosis include productive cough, fever, fatigue, weight loss, hemoptysis, and night sweats. In cases of active pulmonary tuberculosis, the organism is transmitted through the air because it is found in the sputum and secretions. The presence of acid fast bacillus in the sputum, secretions, or tissues of the client is the only method to confirm the diagnosis of active tuberculosis.

A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching? States that pain is an 8 on a scale of 0 to 10 States that her partner should be given the information Expresses concern about the exercises causing pain when performed after surgery Expresses uncertainty about the benefits of the exercises

States that pain is an 8 on a scale of 0 to 10 The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client indicates the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. A key principle of teaching and learning is to first determine the client's readiness and ability to learn. Physical symptoms, such as pain, fatigue, or anxiety, can prevent the client from learning because of a reduced ability to focus on and participate in education.

A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? Notify the provider. Obtain a chest x-ray. Flush the catheter. Stop the infusion.

Stop the infusion. The content of this question emphasizes the concept of priority setting by determining the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. Stopping the infusion is the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. This prevents further damage to vessel and minimizes any additional harm to the client.

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions? Prone with head of the bed flat Dorsal recumbent with head of the bed elevated to 15° Supine with head of the bed elevated to 30° Side-lying with head of the bed elevated to 45°.

Supine with head of the bed elevated to 30° The content of this question emphasizes the concept of safety through selection of the appropriate position for a child who is postoperative following a supratentorial craniotomy. Safety in nursing practice is the minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Following a supratentorial craniotomy, the client should be maintained in a position that facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain. Positioning the client supine with the head of the bed elevated to 30° is appropriate.

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first? Take an ABG specimen to the laboratory. Transport a client to the radiology department for an x-ray. Obtain a clean catch urine sample from a newly admitted client. Pass fresh water to clients.

Take an ABG specimen to the laboratory. The content of this question emphasizes the concept of leadership by prioritizing completion of assigned tasks. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. When making assignments, a leader should be certain to include a timeline for completion. ABG samples are kept on ice and should be transported immediately to the laboratory or the specimen will deteriorate, which will cause inaccurate and meaningless results. This is the task the nurse should instruct the AP to perform first.

A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective? Toast with peanut butter Apple juice Yogurt with fresh fruit Beef broth

Toast with peanut butter In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and manifests as a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations. Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some foods and includes others as appropriate food choices reduces the occurrence and severity of dumping syndrome. Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome.

A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries? Twisting at the waist and shoulders Standing with feet in a wide stance Positioning self close to the client Using arms and legs to lift

Twisting at the waist and shoulders In this item, you need nursing knowledge related to body mechanics. Based on an understanding of this concept, you can identify which option describes an action by the nurse that does not reflect good body mechanics. This is a negatively worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the use of appropriate body mechanics. To prevent a lift injury when transferring the client from the bed to a chair, alignment of the back, neck, pelvis, and feet should be maintained to reduce the risk of injury to the lumbar vertebrae. This action by the newly licensed nurse is not appropriate and indicates a need for additional teaching.

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication? Weight loss ​WBC 2,800/mm3 Heart rate 64/min Insomnia

WBC 2,800/mm3 ​In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Clozapine is a second-generation antipsychotic used to relieve symptoms of schizophrenia and to reduce suicidal behaviors in clients who have schizophrenia or schizoaffective disorder. Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis, which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal. Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3 indicates the client is experiencing an adverse effect of the medication.

A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops? Place the child on the affected side for several minutes upon completion of instillation. Warm refrigerated drops to room temperature prior to instillation. Pull the pinna of the ear upward and back during instillation. Massage the area posterior to the ear after instillation.

Warm refrigerated drops to room temperature prior to instillation. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is an appropriate action by the nurse when administering ear drops. Ear drops are topically administered medications, which are slowly absorbed through the skin and primarily provide local results. Because of the anatomy of internal ear structures, it is important to remember that the ear is sensitive to extremes in temperature. Ear drops should be warmed to room temperature prior to instillation to reduce the risk of painful stimuli.

A nurse is collecting data on four clients. Which of the following findings is the most urgent? Bladder distension and urgency Pedal edema Warmth and pain in the calf Hypoactive bowel sounds

Warmth and pain in the calf Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is warmth and pain in the calf of a client. Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the most urgent need. This option is further supported by the ABC priority setting framework.

A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching? "My child will need to be followed medically for at least 5 years." "My child can resume moderate activity after his fever subsides." "This illness will not recur because my child has now had it." "In a few weeks or months my child could experience sudden, involuntary movements."

"This illness will not recur because my child has now had it." To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Question: Which of the following statements by the parent indicates a need for further teaching? Person of Focus: The nurse who is reinforcing teaching Key Words: teaching, rheumatic fever, statements, further teaching So, the question is asking which statement, when made by the parents, is not appropriate and indicates a need for further teaching. This is a negatively worded, traditional multiple choice item, which means there are four options. Of these options, three are true statements, called the distracters, and one is a false statement, which is the key because the item is negatively worded. Because the question indicates there is only one key, it is not a priority setting item. Next you should review each option and determine if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. "This illness will not recur because my child has now had it" is correct. It is possible for rheumatic fever to recur, so prophylactic treatment with monthly IM injections of benzathine penicillin G, or daily oral doses of penicillin or sulfadiazine, will be needed. This statement by the parent is not appropriate and indicates a need for further teaching.

A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform an electronic blood pressure measurement? A client who is recovering from a cardiac catheterization A client who is in stage 4 of Parkinson's disease A client who has anorexia and hypotension A client who has a temperature of 39.1° C (102.4° F) and is shivering

A client who is recovering from a cardiac catheterization In this item, you need nursing knowledge of how blood pressure measurement can be impacted by the stages of Parkinson's disease, hypotension, shivering, and cardiac catheterization. Additionally, specific knowledge of electronic blood pressure measurement is needed to select the correct option. This item requires critical thinking because you have to analyze the four clients and determine for whom an electronic blood pressure is appropriate. Electronic blood pressure measurement is attained through a sensor that detects vibrations caused by blood rushing through the artery, is appropriate for use when the blood pressure must be monitored frequently, and should not be taken on clients with conditions that can result in an inaccurate reading. A client who is recovering from a cardiac catheterization requires frequent blood pressure measurements. It is appropriate to perform an electronic blood pressure measurement on this client.

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief? Anger Acceptance Bargaining Denial

Bargaining To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is scheduled for a biopsy of a tumor located in her left lower lobe. The client states, "I will quit smoking if the results don't come back positive for cancer." Question: This statement indicates the client is in which of the following stages of grief? Person of Focus: The client scheduled for the biopsy of a lung tumor Key Words: tumor, left lower lobe of lung, "I will quit if" So, the question is asking which of the stages of grief is client is in. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Bargaining is correct. Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.

While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take? Reposition the client every 4 hr. Cover the area with a transparent wound barrier. Massage areas surrounding the redness. Wash the area with hot water every 8 hr.

Cover the area with a transparent wound barrier. In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. This item requires foundational thinking because you have to recall interventions that are appropriate for maintaining skin integrity in clients who are immobile. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1 pressure ulcer. A transparent wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent contamination and reduce friction to the area is an appropriate action by the nurse.

A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client? Mammogram every year to detect breast cancer Colonoscopy every 10 years to detect colon cancer Dermatologist evaluation every 3 years to detect skin cancer Complete eye examination every year to detect eye disorders

Dermatologist evaluation every 3 years to detect skin cancer The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A dermatologist evaluation every 3 years is an appropriate screening to recommend to a 35-year-old client. Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations.

A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider? Tachycardia Vomiting Hypotension Dilated pupils

Tachycardia To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is admitted with acute alcohol withdrawal. Question: Which of the following findings should the nurse report to the provider? Person of Focus: The client admitted with acute alcohol withdrawal Key Words: acute alcohol withdrawal, findings, report to the provider So, the question is asking which of the findings the nurse should report to the provider. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option.Tachycardia is correct. Symptoms of acute alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. These can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and grand mal seizures. Acute alcohol is a medical emergency and can cause death if not treated with the appropriate interventions. Tachycardia indicates the client is in acute alcohol withdrawal and should be reported to the provider.

A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should include that the disease is transmitted in which of the following ways? Vector Airborne Vehicle Bloodborne

Vector To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. Question: The nurse should include that the disease is transmitted in which of the following ways? Person of Focus: The nurse who is reinforcing the teaching Key Words: Lyme disease, transmitted So, the question is asking which of the modes is how Lyme disease is transmitted. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Vector is correct. Vectors are arthropods, which carry and transmit certain illnesses. Examples of illnesses transmitted by vectors include malaria, which is transmitted by mosquitos, and Rocky Mountain spotted fever, which is transmitted by ticks. Lyme disease is transmitted by ixodid, or deer ticks, which is a vector.

A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective? "I am wide awake now." "My mouth is very dry." "I feel very relaxed." "My heart is racing."

"I feel very relaxed." To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam preoperatively. Question: Which of the following statements by the client indicates the medication has been effective? Person of Focus: The client who received the preoperative dose of lorazepam Key Words: administers, lorazepam (Ativan), preoperatively, effective So, the question is asking which client statement indicates the medication has been effective. This was a positively worded, traditional multiple choice item, which means there were four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you have to review each option and determined if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. "I feel very relaxed" is correct. Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety. This statement by the client indicates the medication has been effective.

A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching? "I should eat frequently." "I should avoid eating 1 to 2 hours prior to my treatment." "I should eat foods served cold." "I should eat low carbohydrate foods."

"I should eat low carbohydrate foods." Scenario: A nurse is reinforcing teaching to a client who is receiving chemotherapy about methods to decrease nausea. Question: Which of the following statements made by the client indicates a need for additional teaching? Person of Focus: The client who has received teaching about methods to decrease nausea. Key Words: teaching, chemotherapy, nausea, statements, need for additional teaching. So, the question is asking which statement included in the options, when made by the client, is not appropriate and indicates a need for additional teaching. This is a negatively worded traditional multiple choice item, which means there will be 4 options. Of these options three will be correct, called the distracters, and one will be incorrect, which will be the key since the item is negatively worded. Since the question indicates there is only one key, it is not a priority setting item. Next you should have reviewed each option and determined if it was probably correct, possibly correct, or probably incorrect and assigned the appropriate code to each option. "I should eat low carbohydrate foods" is correct. Clients who are experiencing nausea should eat foods high in carbohydrates, such as crackers, yogurt, toast, bananas, and sherbet. This is not an appropriate statement by the client and indicates a need for further teaching. If you missed this item, your remediation should include an overview of nutritional strategies that reduce nausea.

A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone (Rocephin) 50 mg/kg IM. The infant weighs 17.6 lb. Available is 500 mg/mL. How many mL should the nurse administer?

0.8 mL To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone 50 mg/kg IM. Question: How many mL should the nurse administer? Person of Focus: The nurse who is preparing to administer the medication Key Words: ceftriaxone, 50 mg/kg IM, infant weighs 17.6 lb, available is 500 mg/mL, mL should nurse administer So, the question is asking how many milliliters of ceftriaxone the nurse should administer. This is a fill in the blank item, requiring a numerical calculation. Next you should set up the equation needed to solve this type of problem and calculated the correct dose. To answer correctly, only a number should have been entered in the provided space. STEP 1: Determine the infant's weight in kg: 2.2 lb / x kg = weight in lb / 1 kg; 2.2 lb / x kg = 17.6 lb / 1 kg. Cross multiply and x = 8 kg STEP 2: Find total of one-time dose: Amount prescribed x kg weight (mg x kg) = total daily dose; 50 mg x 8 kg = 400 mg STEP 3: What is the dose needed? Dose needed = Desired; Desired = 400 mg STEP 4: What is the dose available? Dose available = Have; Have = 500 mg STEP 5: Do the units of measure need to be converted? No (mg = mg) STEP 6: What is the quantity of the dose available? Quantity = 1 mL STEP 7: Set up an equation using knowledge about basic equivalents. Desired x Quantity / Have = Amount to be given; 400 mg x 1 mL / 500 mg = x mL; 400 x 1 = 400 ÷ 500 = 0.8 mL STEP 8: Reassess to determine if the amount to be given seems plausible. If there are 500 mg in 1 mL and the prescribed dose is 400 mg, it makes sense to administer 0.8 mL. The nurse should administer 0.8 mL ceftriaxone IM. If you missed this item, your remediation should include an overview of dosage calculations, particularly weight-based calculations.

A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? 1/2 inch 5/8 inch 1 inch 1 1/2 inch

1 1/2 inch To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Question: Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? Person of Focus: The nurse who is preparing to administer an IM injection Key Words: IM injection, needle lengths, ventrogluteal muscle So, the question is asking which of the needle lengths is appropriate for administering an injection in the ventrogluteal muscle. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 1 1/2 inch is correct. A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.

A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25 mg every 6 hr as needed. Available is diphenhydramine 12.5mg/5mL syrup. How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose?

2 tsp To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25 mg every 6 hr as needed. Available is diphenhydramine 12.5mg/5mL syrup. Question: How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose? Person of Focus: The nurse who is instructing the parents about administering diphenhydramine. Key Words: diphenhydramine 25 mg, available is diphenhydramine 12.5 mg / 5 mL syrup, teaspoons per dose. So, the question is asking the number of teaspoons of diphenhydramine the nurse should teach the parents to administer for each dose. This is a fill in the blank item, requiring a numerical calculation. Next you should set up the equation to solve this type of problem and calculate the correct dose. To answer correctly, only a number should be entered in the provided space. To answer this calculation fill in the blank question, the nurse should be able to convert 10 mL of medication into a household measurement (teaspoon). The child needs to receive 10 mL of diphenhydramine. There is 5 mL in one teaspoon, so 10 mL = (10 / 5) = 2 tsp. Therefore, you should enter the numeral 2 in the box without any units or spacing devices. STEP 1: What is the dose needed? Dose needed = Desired; 25 mg STEP 2: What is the dose available? Dose available = Have; 12.5 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg) STEP 4: What is the quantity of the dose available? 5 mL STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 25 mg x 5 mL / 12.5 = x mL; 25 x 5 / 12.5 = 125 ÷ 12.5 = 10 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 10 mL / x; 5x = 10; x = 2 tsp. STEP 6: Reassess to determine if the amount to be given makes sense. If there are 12.5 mg/mL and the prescribed amount is 25 mg, it makes sense to give 10 mL, which equals 2 tsp. The nurse should teach the parents to administer diphenhydramine 2 tsp per dose. If you missed this item, your remediation should include an overview of dosage calculations, as well as converting milliliters to teaspoons.

A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first? A client 48 hr following abdominal surgery with redness and swelling at the edges of the incision A client following knee replacement surgery complaining of pain and warmth in the calf A client admitted with cholecystitis who reports frequent nausea and vomiting A client admitted with a GI bleed receiving packed RBCs for hemoglobin of 7.8 gm/dL

A client following knee replacement surgery complaining of pain and warmth in the calf Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten the client's survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option describes the most unstable client. Thromboembolism is a potentially serious complication after joint surgeries, particularly those involving the lower extremities. Pain, warmth, and redness are all potential clinical manifestations of a thromboembolism, which can lead to the development of a pulmonary embolism. Based on the unstable versus stable priority setting framework and nursing knowledge, this is the client the nurse should evaluate first.

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A client who has COPD with an oxygen saturation of 90% A client who has diabetes mellitus with a HbA1C of 9% A client who has heart failure with 2+ pitting edema of the lower extremities A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant

A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Nursing knowledge might also be needed to determine which option describes an acute need. Heart failure is a chronic condition that results in fluid volume excess because of reduced cardiac output. A fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant is an acute finding that indicates possible appendicitis. Based on the acute versus chronic priority setting framework, this is the client the nurse should evaluate first.

A nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern? A client who is 26 weeks of gestation and reporting leukorrhea A client who is 10 weeks of gestation and reporting urinary frequency A client who is 37 weeks of gestation and reporting perineal discomfort A client who is 34 weeks of gestation and reporting abdominal tenderness

A client who is 34 weeks of gestation and reporting abdominal tenderness Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients get priority because of needs that threaten the client's survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option describes the most unstable client. Abdominal, or uterine tenderness, is an early clinical finding associated with abruption placenta, which could lead to an unstable status. Based on the unstable versus stable priority setting framework and nursing knowledge, this is the client that should be the nurse's priority concern.

A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider? A client who has diabetes mellitus with a fasting blood glucose of 150 mg/dL A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L A client who is prescribed oxygen therapy and albuterol (Proventil) with a PCO2 of 50 mm Hg A client who has urosepsis with a WBC count of 15,000 mm3

A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reviewing the laboratory results of four clients. Question: Which of the following should be immediately reported to the provider? Person of Focus: The nurse who is reviewing the laboratory results Key Words: laboratory results, four clients, immediately, reported So, the question is asking which of the laboratory values should be immediately reported to the provider. This is a positively worded, traditional multiple choice item, which means there are four options. The key word "immediately" in the question indicates this is a priority setting item, which means all four options are correct, but one takes priority over the others. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. A client who is prescribed digoxin and furosemide with a potassium of 3.1 mEq/L is correct. This value is clearly abnormal and indicates that the client has hypokalemia, or decreased potassium. This is a common complication with the use of loop diuretics, such as furosemide. The nurse should also note that the client receives digoxin. Hypokalemia places the client at increased risk for digoxin toxicity, so this is the client who is at immediate risk for injury and whose laboratory findings should be reported to the provider.

A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention? A client who has cystic fibrosis and has a paroxysmal cough A client who is prescribed cromolyn sodium (Crolom) and has a peak expiratory flow rate of 79% A client who has celiac disease and abdominal distention A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting

A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Nursing knowledge might also be needed to determine which option describes an acute need. Vomiting, slow heart rate, and anorexia are clinical findings associated with digoxin toxicity, which is an acute condition. Based on the acute versus chronic priority setting framework, this is the client that requires immediate intervention.

A nurse working the 7 p.m. to 7 a.m. shift on the pediatric unit has received report on four postoperative clients. Which of the following requires immediate intervention? An adolescent who is postoperative following an appendectomy and has refused to ambulate for the past 8 hr A school-age child who is postoperative following a herniorrhaphy with an infiltrated peripheral IV that has been clamped A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing An infant who is postoperative following a cleft palate repair with a heart rate of 146/min and a respiratory rate of 28/min

A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients get priority because of needs that threaten the client's survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option describes the most unstable client. A preschooler who is experiencing frequent swallowing following a tonsillectomy could be bleeding, placing the client at risk for hemorrhage. Bleeding from the surgical site can cause the dripping of blood down the back of the throat, which results in frequent swallowing or clearing of the throat and indicates the client could be unstable. Based on the unstable versus stable priority setting framework and nursing knowledge, the client requires immediate intervention. This option is further supported by the ABC priority setting framework.

A nurse is caring for a client who is 48 hr postoperative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? Absent bowel sounds Serum BUN level 22 mg/dL Absent dorsalis pedis pulses Serum creatinine level of 1.3 mg/dL

Absent dorsalis pedis pulses Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is absent dorsalis pedis pulses. Absence of these pulses indicates that a graft occlusion following an abdominal aortic aneurysm repair is blocking circulation. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the most urgent need. This option is further supported by the ABC priority setting framework.

A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning? Advocate Clinician Educator Manager

Advocate Scenario: A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. Question: In which of the following roles is the nurse functioning? Person of Focus: The nurse who is working with administration to enhance the quality of care provided to clients during the prenatal period Key Words: working with, enhance, quality of care, roles, functioning So, the question is asking in which of the following roles is the nurse functioning. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracter. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Advocate is correct. A nurse advocate acts as a liaison between clients and providers in order to improve or maintain the quality of care that clients receive. The nurse is functioning in the role of the nurse advocate for the clients during the prenatal period.

A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? Aspirin (Bayer) Acetaminophen (Tylenol) Guaifenesin (Robitussin) Diphenhydramine hydrochloride (Benadryl)

Aspirin (Bayer) To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). Question: The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? Person of Focus: The nurse who is reinforcing teaching about captopril Key Words: captopril, reduce, antihypertensive effects So, the question is asking which of the medications should be reinforced to the client as having the potential to reduce the antihypertensive effect of captopril. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Aspirin is correct. Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that aspirin has the potential to reduce the antihypertensive effect of captopril and should be avoided.

A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. The client reports a burning pain in his chest. Which of the following actions by the nurse is appropriate? Assist the client to a side-lying position. Remove 10 mL of water from the suction control chamber. Apply a padded clamp on the tubing for 1 to 2 min. Move the drainage system above the level of the client's heart.

Assist the client to a side-lying position. In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Burning sensation or pain can result from the chest tube becoming occluded because it is resting against tissue. It is possible to move the tip of the chest tube away from the tissues by repositioning the client. Repositioning the client is the appropriate action by the nurse.

A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first? Administer an analgesic. Assist the client to shift positions. Check pedal pulse. Distract the client with music therapy.

Check pedal pulse. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Pressure on the peroneal nerve can occur when skin traction is applied to lower extremities, which can result in foot drop. This can be manifested as a burning sensation under the traction bandage or boot. Reduced circulatory impairment can also result in the sensation of pain. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor? Diplopia Loss of bladder control Paresthesias Decreased respiratory effort

Decreased respiratory effort Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are priority concerns of the nurse caring for a client who has myasthenia gravis. Myasthenia gravis affects neuromuscular transmission of the voluntary muscles of the body. Progressive weakness of the diaphragmatic and intercostal muscles can produce respiratory distress. Based on this knowledge and using the ABC priority setting framework, it is most important for the nurse to monitor for respiratory difficulty.

A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply.) Drooling Stridor Difficulty swallowing Croupy cough High-grade fever

Drooling Stridor Difficulty swallowing High-grade fever Scenario: A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Question: Which of the following clinical findings are associated with the illness? Person of Focus: The child who is diagnosed with bacterial epiglottitis Key Words: bacterial epiglottitis, clinical findings, associated, select all that apply So, the question is asking which clinical findings are associated with bacterial epiglottitis. This is a positively worded, multiple response item, which means there are five or six options. Of these options, two or more are correct. Because the item includes both correct and incorrect options, and you have to select only the correct options, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option.

A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion? Dullness Hyper-resonance Resonance Tympany

Dullness To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is performing a respiratory examination on a client who has pneumonia. Question: Which of the following sounds should be elicited over areas of consolidation during percussion? Person of Focus: The client who has pneumonia Key Words: respiratory examination, sounds, consolidation, during percussion So, the question is asking which of the sounds heard during percussion should be elicited over areas of consolidation. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Dullness is correct. Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation.

A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? Administer an anti-anxiety medication. Take the client to a place of seclusion. Obtain an order for soft wrist restraints. Engage the client in physical activity.

Engage the client in physical activity. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. Physical or chemical restraints should only be used when the safety of the client, staff, or others is at risk. Gross motor activities can reduce tension and lower anxiety levels. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than others and should be the first action of the nurse.

A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first? Evaluate level of consciousness. Place the client on bed rest. Encourage increased fluid intake. Initiate continuous ECG monitoring.

Evaluate level of consciousness. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client so a plan of care can be developed. Clients who have a fractured hip are at risk for fat embolism syndrome because of the release of fat globules from the yellow bone marrow. These globules enter the blood stream where they can travel and occlude small vessels and impair perfusion to vital organs, including the lungs. A change in the level of consciousness is the earliest manifestation of fat embolism syndrome. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care. This option is further supported by the ABC priority setting framework.

A nurse is caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast? Promote adequate intake of calcium. Evaluate neurovascular status. Elevate the extremity above the heart. Apply ice intermittently for the first 24 hr.

Evaluate neurovascular status. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Neurovascular compromise is a manifestation of compartment syndrome and must be detected in the early stages to avoid permanent damage. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care. This action can be further supported as the priority action using the ABC priority setting framework.

A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (Select all that apply) Cooked oatmeal Grape juice Applesauce Ice cream Smooth peanut butter

Grape juice Ice cream To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who has been prescribed a full liquid diet. Question: Which of the following is appropriate to include in the client's diet? Person of Focus: The client who has been prescribed a full liquid diet Key Words: full liquid diet, appropriate, include, select all that apply So, the question is asking which of the foods are appropriate to include in a full liquid diet. This is a positively worded, multiple response item, which means there are five or six options. Of these options, two or more are correct. Because the item included correct and incorrect options and you had to select only the correct options, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Grape juice is appropriate to include in both a clear liquid and a full liquid diet. Ice cream is appropriate to include in a full liquid diet.

A nurse is caring for a client who is receiving vancomycin (Vancocin) for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor? Respiratory depression Hearing loss Hypertension Bradycardia

Hearing loss To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is receiving vancomycin for a beta-hemolytic streptococci infection. Question: For which of the following adverse effects should the nurse monitor? Person of Focus: The client who is receiving vancomycin Key Words: laboratory values, indicates, nephrotoxicity So, the question is asking which finding the nurse should monitor for in a client who is receiving vancomycin. This was a positively worded, traditional multiple choice item, which means there were four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next, you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Hearing loss is correct. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss. The nurse should monitor for this adverse effect.

A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? Homelessness Lack of family support ​Hypoxic Under nourished

Hypoxic ​Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level of Maslow's Hierarchy of Needs. Because oxygen is considered the most basic physiological need, this is the need the nurse should address first. This is further supported using the ABC priority setting framework.

A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care? Include the family in the client's care. Identify one's own beliefs and values. Determine the client's cultural beliefs. Encourage the client to discuss the influence of illness on cultural practices.

Identify one's own beliefs and values. Scenario: A nurse is caring for a client who is from a culture different than his own. Question: Which of the following actions by the nurse is most important in the provision of culturally competent care? Person of Focus: The nurse caring for client who is from a different culture Key Words: culture, different, actions, most important, culturally competent care So, the question is asking which of the actions is most important for the nurse to take in the provision of culturally competent care. This is a positively worded, multiple choice item. The key word "most" in the question indicates this is a priority setting item, which means all four actions are important in the provision of culturally competent care, but one action is the most important. Next you should review each option and determine which should be performed first. Identify one's own beliefs and values is correct. To provide culturally competent care, it is essential to identify one's own cultural background, values, and beliefs, especially those that are related to health and health care. This is the most important action by the nurse.

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern? Facial abrasions Penetrating head wound Incomplete amputation of the foot Tibia fracture requiring open reduction

Incomplete amputation of the foot Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client who has injuries that are severe, but has the potential to survive with treatment. A client with an incomplete amputation of the foot should be assigned to the immediate triage category because injuries are life-threatening, but survivable if immediate care is received. The nurse should place highest priority on this client.

A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? Percussion Palpation Auscultation Inspection

Inspection To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. Question: When examining the abdomen, which of the following techniques should the nurse perform first? Person of Focus: The client who is reporting abdominal discomfort Key Words: examining, techniques, first So, the question is asking which of the techniques the nurse should perform first when examining the abdomen. This is a positively worded, multiple choice item. The key word "first" in the question indicates this is a priority setting item, which means all four options are correct, but one takes priority over the others. In this item, all four techniques are performed when examining the abdomen, but one of the techniques should be performed before the others. Next you should review each option and determined which to perform first. Inspection is correct. Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen.

A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting a low-pitched diastolic murmur? Supine position Left lateral recumbent position Sitting position Dorsal recumbent position

Left lateral recumbent position To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to auscultate a client's heart. Question: Which of the following positions is best for detecting a low-pitched diastolic murmur? Person of Focus: The nurse who is preparing to auscultate the client's heart Key Words: auscultate, heart, positions, best, low-pitched diastolic murmur So, the question is asking the best position for detecting a low-pitched murmur. This is a graphic option item, which is similar to traditional multiple choice items except images are used in the options instead of text. The key word "best" in the question indicates this is a priority setting item, which means all four options are correct, but one is better than the others. In this item, all four positions can be used to auscultate the heart, but one position is the best for detecting low-pitched murmurs. Next you should review each option and determine which position is the best. This is the correct position. This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.

​A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. (Selectable areas, or "Hot Spots," can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)

Lower right quadrant Scenario: A nurse is collecting data on a client who has appendicitis. Question: Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. Person of Focus: The nurse who is palpating for tenderness at McBurney's point Key Words: appendicitis, site, palpate, tenderness at McBurney's point So, the question is asking the location the nurse should palpate to determine the presence of tenderness at McBurney's point. This is a Hot Spot item, which means an image is provided with clickable "Hot Spots" in various locations on the image Next you should roll the cursor over the image to locate all Hot Spots and determine if each is probably correct, possibly correct, or probably incorrect. Then, you had to click on one of the Hot Spots to select it as the correct option. This is the site the nurse should palpate. McBurney's point is located in the lower right quadrant midway between the anterior iliac crest and the umbilicus. Pressure over this point will elicit pain in the later stages of appendicitis. Remember, the screen is not a mirror image; you had to identify the client's right side.

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor? Maternal respirations Fetal heart rate Maternal deep-tendon reflexes Maternal urinary output

Maternal respirations Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs and the fetus via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are priority concerns of the nurse caring for a client who is in preterm labor and is receiving magnesium sulfate. Excessive levels of magnesium can suppress neuromuscular transmission, placing the client at risk for respiratory depression. Based on this knowledge and using the ABC priority setting framework, it is most important for the nurse to monitor maternal respirations.

A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following? Mood Immunity Memory Vitality

Mood To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is a provider's office is caring for a client who has depression and is taking St. John's Wort. Question: The herbal supplement is thought to improve which of the following? Person of Focus: The client who is taking St. John's Wort Key Words: depression, St. John's Wort, improve So, the question is asking which of the characteristics is thought to improve by taking St. John's Wort. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Mood is correct. St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety.

A nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse? Administer nebulized epinephrine (racemic epinephrine). Ensure adequate hydration. Obtain an oxygen saturation level. Encourage parents to comfort the client.

Obtain an oxygen saturation level. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Laryngotracheobronchitis can result in impaired airway clearance because of upper airway swelling and increased respiratory effort. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak? Lethargy Neuralgia Bradycardia Oliguria

Oliguria To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is assessing a client who is postoperative following a gastric bypass. Question: Which of the following findings indicates the client could be experiencing an anastomotic leak? Person of Focus: The client who is postoperative following a gastric bypass Key Words: postoperative, gastric bypass, findings, anastomotic leak So, the question is asking which of the findings indicates the client is experiencing an anastomotic leak. This was a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Oliguria is correct. When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine production, is a finding consistent with peritonitis and can indicate the client is experiencing an anastomotic leak.

A nurse is caring for a client who was admitted to the unit 3 hr ago following a total hip arthroplasty. Which of the following findings should be nurse's priority concern? Urinary output of 75 mL over the past 3 hr 8-point elevation in the pre-surgery diastolic blood pressure Oxygen saturation of 90% on oxygen at 2 L per nasal cannula Core body temperature of 36.2° C (97.2° F)

Oxygen saturation of 90% on oxygen at 2 L per nasal cannula Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is an oxygen saturation of 90% on oxygen at 2 L per nasal cannula. Hypoxemia can be caused by a number of potentially life-threatening conditions in the postoperative period, such as atelectasis, pulmonary edema, or pulmonary embolism. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the nurse's priority concern.

A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer? Partial thickness skin loss Visible subcutaneous fat Nonblanchable redness Exposed muscle

Partial thickness skin loss To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is immobile and has developed a pressure ulcer. Question: Which of the following characteristics is associated with a stage II pressure ulcer? Person of Focus: The client who has developed a pressure ulcer Key Words: pressure ulcer, characteristics, stage II So, the question is asking which of the characteristics is associated with a stage II pressure ulcer. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Partial thickness skin loss is correct. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister.

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first? Bathe a client who is scheduled for physical therapy at 9 a.m. Perform fingersticks for glucose levels on clients who have diabetes mellitus. Stock procedure rooms. Distribute clean linens.

Perform fingersticks for glucose levels on clients who have diabetes mellitus. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Performing fingersticks for glucose levels on clients who have diabetes mellitus is important in order to ensure physiological safety of the clients. Using the safety and risk reduction priority setting framework and nursing knowledge, the greatest risk to the client is hyperglycemia or hypoglycemia because of inadequate or inappropriate amounts of insulin being administered. To attain accurate readings, these levels should be attained prior to eating; therefore, this is the task the nurse should have the AP perform first.

A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse? Wrap the cord in a towel saturated with 0.9% sodium chloride. Apply oxygen via face mask. Place client in knee-chest position. Increase IV fluid rate.

Place client in knee-chest position. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. Question: After calling for assistance and notifying the provider, which of the following is the priority action by the nurse? Person of Focus: The fetus whose heart rate has decreased to 50/min Key Words: labor, visualizes, umbilical cord, fetal heart rate is 50/min, after calling, priority action So, the question is asking which of the actions is the priority after calling for help and notifying the provider. This is a positively worded, multiple choice item. The key word "priority" in the question indicates this is a priority setting item, which means all four options are correct, but one takes priority over the others. In this item all four actions are performed in the event of a prolapsed cord, but one of the techniques should be performed before the others. Next you should review each option and determine which is the priority action.Place client in knee-chest position is correct. Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the fetus off the cord. Using the ABC priority setting framework, the greatest risk is the cessation of circulation to the fetus; therefore, this is the priority action the nurse should take.

A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is the priority concern of the nurse? Enhancing self-esteem Preventing injury Encouraging problem solving Promoting usefulness

Preventing injury Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The second level of Maslow's Hierarchy of Needs includes needs associated with safety and security; therefore, preventing injury is the priority action of the nurse.

A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? Promoting oxygenation Management of pain Maintaining hydration Preventing infection

Promoting oxygenation Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are the priority concerns of the nurse caring for a client who has been admitted in a vaso-occlusive crisis. Short-term oxygen therapy is used to prevent additional sickling and hypoxia. Massive systemic sickling has been linked to severe hypoxia and can be fatal. Rest should also be encouraged to decrease expenditure of energy and oxygen. Based on this knowledge and using the ABC priority setting framework, promoting oxygenation is the nurse's priority concern.

A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.) Request prescription for iron supplement. Administer 4 oz of orange juice. Restrict fluid intake. Encourage bed rest.

Restrict fluid intake. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse on a rehabilitation unit has just received report on a client who was admitted 3 days ago. Question: Upon review of the client's medical record, which of the following actions should the nurse take? Person of Focus: The nurse caring for the client who was admitted to the rehabilitation unit 3 days ago Key Words: review, medical record, actions This is a positively worded exhibit item presented as a traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review the additional data presented in each of the tabs to determine if each option is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Restrict fluid intake is correct. Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.

A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations? Hypertension and crackles Excessive thirst Shakiness and diaphoresis Twitching muscles

Shakiness and diaphoresis To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's TPN is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. Question: The nurse should monitor the client for which of the following manifestations? Person of Focus: The client who has been off the unit for physical therapy Key Words: infusion pump, turned off, TPN So, the question is asking which manifestation the nurse should observe for when TPN has been abruptly stopped. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Shakiness and diaphoresis is correct. The nurse should observe the client for shakiness and diaphoresis. These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below the prescribed amount.

A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client? Lithotomy Dorsal recumbent Prone Sims'

Sims' To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to administer a tap water enema to a client. Question: In which of the following positions should the nurse place the client? Person of Focus: The client who is being prepared for administration of an enema Key Words: tap water enema, positions So, the question is asking which of the positions the nurse should place the client to administer a tap water enema. This is a positively worded, traditional multiple choice item, which means there are be four options. Of these options, one is be correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Sims' is correct. The left side-lying, or Sims' position, places the client on the side with the knee flexed. This position allows the enema to flow along the curve of the sigmoid colon and rectum naturally, which improves retention of the solution.

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching? Lentils Soybeans Broccoli Oatmeal

Soybeans Scenario: A nurse is reinforcing teaching regarding foods containing complete protein to a client. Question: Which of the following should be included in the teaching? Person of Focus: The nurse who is reinforcing teaching about complete proteins Key Words: teaching, complete protein, foods, included So, the question is asking which of the foods are complete sources of protein and should be included in the teaching. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Soybeans is correct. Food sources of complete proteins contain sufficient quantities of all nine essential amino acids to support body growth and maintenance. Soybeans are a source of complete protein and should be included in the teaching.

A nurse is a caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder? Grandiose sense of self importance Reckless disregard for safety of others Unstable interpersonal relationships Lack of empathy

Unstable interpersonal relationships To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is a caring for a client who has borderline personality disorder. Question: Which of the following is a manifestation of the disorder? Person of Focus: The client who has borderline personality disorder Key Words: borderline personality disorder, manifestation So, the question is asking which manifestation is a characteristic of borderline personality disorder. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Unstable interpersonal relationships is correct. Borderline personality disorder is characterized by unstable interpersonal relationships, emotional instability, impulsivity, unstable mood, and self image distortions.

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury? Lock knees. Stand close to the client. Keep feet close together. Move client by twisting at the waist.

Stand close to the client. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who needs assistance moving from the bed to a chair. Question: The nurse should take which of the following actions to prevent a lift injury? Person of Focus: The client who is being transferred from the bed to a chair Key Words: transfer, prevent, lift injury So, the question is asking which of the actions the nurse should take to prevent sustaining an injury when transferring a client from the bed to a chair. This is a positively worded, traditional multiple choice item, which means there will be four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Stand close to the client is correct. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client. Standing close to the client decreases reaching for the client and reduces stress on the nurse's back.

A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? (Click on the audio button to hear the breath sounds.) Rhonchi Crackles Stridor Wheezes

Stridor To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination, the nurse hears the sound in the provided audio clip. Question: Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? Person of Focus: The infant diagnosed with laryngotracheobronchitis Key Words: laryngotracheobronchitis, respiratory examination, hears, audio clip, breath sound So, the question is asking which of the manifestations the nurse hears when performing a respiratory assessment. This is an audio format item, which means you have to listen to the provided audio to determine the correct answer. There are four options; one which is correct, called the key, and three that are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Stridor is correct. Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchitis. The breath sound on the audio clip is an example of stridor.

A nurse in a rehabilitation center is caring for a client who has just had a cerebrovascular accident. Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider? Temperature 37.6º C (99.8º F) Blood glucose level 144 mg/dL Dry mouth Headache

Temperature 37.6º C (99.8º F) Scenario: A nurse is caring for a client in a rehabilitation center following a cerebrovascular accident. Question: Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider? Person of Focus: The nurse caring for the client who has had a cerebrovascular accident Key Words: cerebrovascular accident, review, medical record, immediately reported to the provider So, the question is asking which of the findings the nurse should report to the provider. This is a positively worded, exhibit item, which is similar to a traditional multiple choice item. The key word "immediately" in the question indicates this is a priority setting item, which means all four options are correct, but one is more important than the others. In this item, all four findings should be reported, but one finding is more urgent and should be reported immediately. Next you should review the additional data presented in each of the exhibit tabs to determine if each option is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Temperature 37.6° C (99.8° F) is correct. Sore throat, malaise, mouth sores, and fever are clinical findings associated with agranulocytosis, a potentially dangerous blood dyscrasia that is an adverse effect of clozapine. Using the urgent versus nonurgent priority setting framework, this is the priority finding and should be reported immediately to the provider.

A nurse is examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes. (Selectable areas, or "Hot Spots," can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)

To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is examining a client's lymphatic system. Question: Identify the site the nurse should palpate to examine the posterior cervical lymph nodes. Person of Focus: The nurse who is examining the client's lymph system Key Words: lymphatic system, identify site, palpate, posterior cervical lymph nodes So, the question is asking the location the nurse should palpate to examine the posterior cervical lymph nodes. This is a Hot Spot item, which means an image is provided with "Hot Spots" indicated in various locations on the image. These Hot Spots indicate the options you have for answering the item. Next you should roll the cursor over the image to locate all of the Hot Spots and determine if each is probably correct, possibly correct, or probably incorrect. Then, you should click on one of the Hot Spots to select it as the correct option. This area, known as the posterior cervical, is correct. While facing the client, the nurse should use the pads of the middle three fingers to gently palpate the nodes in a circular motion and evaluate each for consistency, characteristics, mobility, warmth, and tenderness. This is the location of the posterior cervical lymph nodes, which are a group of lymph nodes located on the sides of the neck.

A nurse is reviewing the electronic fetal heart rate tracing of a client who is in labor. Which of the following images exhibits variable decelerations?

To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reviewing the electronic fetal heart rate tracing of a client who is in labor. Question: Which of the following images exhibits variable decelerations? Person of Focus: The fetus whose heart rate is experiencing variable decelerations Key Words: fetal heart rate tracing, labor, images, variable decelerations So, the question is asking which of the images represents variable decelerations. This is a positively worded, graphic option item, which is similar to traditional multiple choice items except images are used in the options instead of text. There are four options; of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review the image in each option and determine which is correct. This is an image of variable decelerations. Variable decelerations are caused from cord compression.

A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? (Select all that apply.) Urinary tract Surgical wound Musculoskeletal system Respiratory tract Blood stream

Urinary tract Surgical wound Respiratory tract Blood stream Health care associated infections are caused from health care delivery in a health care facility. These result from prescribed antibiotic administration, presence of multi-medication resistant organisms, breeches in infection control practices, and invasive procedures. The urinary tract is a common site for health care associated infections. Surgical wounds are a common site for health care associated infections. The respiratory tract is a common site for health care associated infections. The blood stream is common site for health care associated infections.

A school nurse is reinforcing teaching regarding bicycle safety to a group of school-age children. Which of the following is the most important concept to include in the teaching? Place proper lights and reflectors on the bicycle. Use a properly-fitted bicycle helmet. Wear light-colored clothing at night. Use hand signals when turning.

Use a properly-fitted bicycle helmet. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It can be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. A properly-fitted bicycle helmet should always be worn to prevent head injuries. Using the safety and risk reduction priority setting framework and nursing knowledge, the greatest risk to the client is blunt trauma to the head. Because adequate brainstem functioning is required to support breathing and circulation, this option is further supported by the ABC priority setting framework.

A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading? Wrapping the cuff loosely around the arm Using a cuff that is too wide Leaving client's arm unsupported Taking client's blood pressure immediately after client sits down

Using a cuff that is too wide To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to measure the blood pressure of a client who has hypertension. Question: Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading? Person of Focus: The client who has hypertension and is having his blood pressure measured by the nurse Key Words: measure, blood pressure, inaccurately low reading So, the question is asking which of the actions can cause an inaccurately low reading. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Using a cuff that is too wide is correct. Using a cuff that is too wide can result in a false low blood pressure reading.

A nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective? "I should leave the patch on for 16 to 20 hours each day." "I will apply a new patch in the same location each day." "The patch should be effective within an hour of being applied." "The medication is not absorbed as well when placed on the abdomen."

"The patch should be effective within an hour of being applied." The content of this question emphasizes the concept of client education by evaluating teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching be an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This statement by the client is true and indicates teaching has been effective. Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.

A nurse is caring for a client who has a new colostomy. The client is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughter states that she doesn't know how she is going to care for her mother's colostomy? "It's quite simple. I'll make sure that her colostomy bag is clean before she leaves and you'll have no problems." "Is the colostomy care the only reason your mother is going to be living with you?" "A home health nurse will be stopping by tomorrow. If you have any questions, you can ask her." "What part of your mother's care concerns you?"

"What part of your mother's care concerns you?" In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Clarification encourages the other person to further express concerns so they can be addressed. This is an appropriate response by the nurse because it uses the communication tool of clarification.

A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed ciprofloxacin (Cipro) 250 mg PO two times daily. The amount available is 100 mg/tablet. How many tablets should the nurse administer with each dose?

2.5 tablets In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the number of tablets the nurse should administer. This item requires critical thinking because you have to analyze the provided facts to determine the dosage, select a formula, enter data into the formula, and then perform the needed calculations. Step 1: What iss the dose needed? Dose needed = Desired; 250 mg Step 2: What is the dose available? Dose available = Have; 100 mg Step 3: Do the units of measurement need to be converted; No (mg = mg) Step 4: What is the quantity of the dose available? 1 tablet Step 5: Set up an equation and solve: Desire x Quantity / Have = Amount to be given; 250 mg x 1 tablet / 100 mg = x tablets; 250 x 1 = 25; x = 2.5 tablets.

A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin (Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose?

2.5 mL gentamicin/dose In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the milliliters of gentamicin that should be added to the 0.9% sodium chloride solution. This item requires critical thinking because you have to analyze the dose on hand, convert the patient's weight to kilograms, and determine the dosage. Then you have to select the formula, enter data into the formula, and perform the needed calculations. STEP 1: Determine the client's weight in kg. 2.2 lb / x kg = weight in lb / 1 kg; 2.2 lb / x kg = 132 lb / 1 kg. Cross multiply and solve for x; 132 ÷ 2.2 = x; x = 60 kg. STEP 2: Find total daily dose: Amount prescribed x kg weight (mg x kg) = total daily dose; 5 mg x 60 kg = 300 mg. Because the medication was prescribed as mg/kg/day, 300 mg is the total daily dose. STEP 3: Find the amount per dose: Total daily dose / number of doses prescribed per day = amount per dose; 300 mg / 3 doses = 100 mg. Because the medication is to be administered in 3 equal doses, 100 mg is the amount per dose. STEP 4: What is the dose needed? Dose needed = Desired; Desired = 100 mg STEP 5: What is the dose available? Dose available = Have; Have = 40 mg STEP 6: Do the units of measure need to be converted? No (mg = mg) STEP 7: What is the quantity of the dose available? Quantity = 1 mL STEP 8: Set up an equation using knowledge about basic equivalents. Desired x Quantity / Have = Amount to be given; 100 mg x 1 mL / 40 mg = x mL; x = 2.5 mL STEP 9: Reassess to determine if the amount to be given makes sense. If there are 40 mg in 1 mL and the prescribed dose is 100 mg, it makes sense to add 2.5 mL to the solution. The nurse should add 2.5 mL gentamicin/dose to the solution.

A nurse is providing discharge education to the parents of a preschooler who is prescribed acetaminophen (Tylenol) 300 mg every 4 hr as needed. The acetaminophen liquid suspension that has been prescribed provides 120 mg/5 mL. How many teaspoons should the nurse teach the parents to administer per dose?

2.5 tsp In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the number of teaspoons the nurse should teach the parents to administer. This item requires critical thinking because you have to analyze the provided information to determine the dosage, select the formula, enter data into the formula, and then perform the needed calculations. Step 1: What is the dose needed? Dose needed = Desired; 300 mg Step 2: What is the dose available? Dose available = Have; 120 mg Step 3: Do the units of measurement need to be converted? No (mg = mg). Step 4: What is the quantity of the dose available? 5 mL Step 5: Set up an equation and solve. Desired x Quantity / Have = Amount to be given; 300 mg x 5 mL / 120 mg = x mL; x = 12.5 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 12.5 mL / x; 5x = 12.5; x = 2.5 tsp.

A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? Check on the client. Unlock the crash cart. Begin cardiopulmonary resuscitation. Announce a code.

Check on the client. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. If the client is able to be aroused or a pulse is palpated, then the client is not in cardiac arrest, and there is a problem with the monitoring equipment. It is common for leads to become loose or fall off clients when they move around, resulting in the monitor detecting an absence of cardiac function. Therefore, checking on the client is the first action the nurse should take.

A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? Provide assistance with ambulation when indicated. Determine the mobility status of each client. Maintain the side rails of each bed in the raised position. Plan a fall prevention program for clients at risk.

Determine the mobility status of each client. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Determining the mobility status of each client will help to identify those patients who are at risk for falls. This knowledge will ensure the implementation of education and prevention efforts specific to the needs of each client. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.) Client shifts weight from crutches to the unaffected leg. Client transfers body weight to the crutches. Client advances the unaffected leg between the crutches. Client stands, bearing weight on unaffected leg. Client aligns crutches on the stair.

Client stands, bearing weight on unaffected leg. Client transfers body weight to the crutches. Client advances the unaffected leg between the crutches. Client shifts weight from crutches to the unaffected leg. Client aligns crutches on the stair. To answer this item you should have started by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority-setting. Let's analyze the item together now.Scenario: A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Question: Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait.Person of Focus: The client who is learning to go up stairs using a modified 3-point crutch gait.Key Words: learning, sequence of actions, up stairs, modified 3-point crutch gait.So, the question is asking for the appropriate sequence of actions when going up stairs using a modified 3-point gait crutch. This is a drag and drop or ordered response item, which means the options were listed unordered in a box on the left side of the screen and had to be "dragged and dropped" into the box on the right side of the screen in the correct order. This is a priority setting item because the options had to be placed in rank order.Next you should have reviewed each option and determined its appropriate placement in the sequence of required actions.

A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching? - mcg - q.d. - mL - PO

q.d. In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module 4. This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "q.d." was previously used to indicate every day, which can be mistaken as the abbreviation for "four times daily (qid)," resulting in medical errors. The Joint Commission has recommended the use of "daily" to indicate every day. This is not an acceptable abbreviation; therefore, additional teaching is needed.

A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate? "I know this must be frightening, but you are going to be fine." ​"Let's talk for a minute about your concerns." "You were transferred because it is in your best interest." "Why do you feel a family member should be with you?"

​"Let's talk for a minute about your concerns." ​The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication helps develop nurse-client relationships that foster trust and respect. "Let's talk for a minute about your concerns" is an appropriate response by the nurse. Discussing the client's concerns and providing appropriate information will lower the client's anxiety level and establish an environment of open communication.