CRITICAL THINKING SCENARIOS

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? A. "I provide indirect care to my clients by coordinating their treatment with other disciplines." B. "Even though I do not provide care to clients, my work is very important." C. "I provide a critical service that is necessary for financial reimbursement." D. "Moving away from client care is a necessary step to advancing my career."

A. "I provide indirect care to my clients by coordinating their treatment with other disciplines."

Which nursing action can be categorized as a surveillance or monitoring intervention? A. Auscultating of bilateral lung sounds B. Administering a paracetamol tablet C. Providing hygiene D. Use of therapeutic communication skills

A. Auscultating of bilateral lung sounds

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the health care providers wrote orders to ambulate the client, whereas another health care provider ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? A. Communicate with the health care providers to coordinate their orders. B. Collaborate with the physical therapist to determine the client's ability. C. Assess the client to determine whether the client is capable of ambulation. D. Instruct the client to ask the health care providers for clarifications of instructions.

A. Communicate with the health care providers to coordinate their orders.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? A. Discuss possible alternatives to a blood transfusion with the health care provider. B. Discuss the risks and benefits of a blood transfusion with the client. C. Discuss the client's options with other church members. D. Discuss the client's refusal with hospital risk managers.

A. Discuss possible alternatives to a blood transfusion with the health care provider.

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? A. Discuss with the client the reasons for declining surgery. B. Ask the client to discuss the decision with family members. C. Notify the health care provider of the client's refusal. D. Review with the client the risks and benefits of surgery.

A. Discuss with the client the reasons for declining surgery.

What teaching will the community health nurse include for parents of toddlers? A. Household cleaners must be kept out of reach. B. Peer pressure can contribute to risk-taking. C. Purchase protective sporting equipment. D. Place the child securely on a changing table.

A. Household cleaners must be kept out of reach.

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? A. Outcome B. Cost-effectiveness C. Process D. Structure

A. Outcome

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? A. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) B. Tuberculosis and pneumonia C. Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus D. Clostridium difficile and diabetic ketoacidosis

A. Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? A. Report the findings to the health care provider for further plans. B. Interview the family to determine if the client is giving accurate information. C. Reinforce the instructions for the treatment regimen to the client. D. Inform the client that the blood pressure medication will have to be changed.

A. Report the findings to the health care provider for further plans.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? A. Risk factors for and prevention of diabetes mellitus B. Medications used to treat diabetes mellitus C. The severity of the client's disease D. The cellular metabolism of glucose

A. Risk factors for and prevention of diabetes mellitus

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of: A. Survival adaptation B. Aerobic activity C. Means of transmission D. Spore production

A. Survival adaptation

The client reports right knee pain of 6/10 on the pain scale and requests medication. The nurse assesses and flushes the intravenous site. Which type of intervention skill is the nurse using? A. Technical skill B. Mechanical skill C. Interpersonal skill D. Intellectual skill

A. Technical skill

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? A. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. B. Individualize the use of restraints and choose the most easily used device. C. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. D. Respond to the past history of the client (including previous falls) to determine the need for restraints.

A. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

A nurse is caring for four clients. Which client has the highest risk of infection? A. older male with an enlarged prostate B. toddler with a benign heart murmur C. young woman with a history of scoliosis D. woman in second trimester of pregnancy

A. older male with an enlarged prostate

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? A. unlicensed assistive personnel who is in nursing school B. senior student in nursing school who is present for clinical C. licensed practical/vocational nurse D. registered nurse

A. unlicensed assistive personnel who is in nursing school

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? A. Inform the client when ambulation is scheduled next. B. Document the client's ambulation. C. Assess the client's response to the ambulation. D. Discuss the client's feelings about the illness.

C. Assess the client's response to the ambulation.

A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness? A. There is really nothing that can be done to prevent childhood illness. B. Grouping infectious children together helps to prevent future infection. C. Early infection treatment is needed to prevent the spread of infection. D. It is recommended that infection in children be allowed to run its course to build immunity.

C. Early infection treatment is needed to prevent the spread of infection.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? A. licensed practical/vocational nurse B. registered nurse C. Unlicensed licensed personnel D. senior student in nursing school who is present for clinical

C. Unlicensed licensed personnel

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action? A. change to standard precautions B. change to contact precautions C. change to airborne precautions D. continue with droplet precautions

C. change to airborne precautions

The nurse is caring for a client who reports having sexual intercourse with someone infected with HIV. The client may have contracted HIV due to which route of transmission? A. vector B. indirect contact C. direct contact D. fomite

C. direct contact

Any microorganism capable of disrupting normal physiologic body processes is a: A. virus. B. fomite. C. pathogen. D. bacterium.

C. pathogen.

A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason? A. helps to determine prescribed antibiotic therapy B. narrows the therapeutic range to avoid prolonged use C. helps in reducing proliferation of multidrug-resistant organisms D. permits selection of antibiotic concentration

A. helps to determine prescribed antibiotic therapy

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply. A. Providing routine discharge instructions related to infant care B. Assisting the client with personal hygiene needs and ambulation C. Assisting and teaching the client to breastfeed the infant D. Initial assessment of the mother after birth of the infant E. Transporting the infant to the mother's room according to hospital policy

B. Assisting the client with personal hygiene needs and ambulation E. Transporting the infant to the mother's room according to hospital policy

The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection? A. reverse isolation B. contact C. airborne D. droplet

B. contact

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments? A. When a sterile item touches something that is not sterile, it may not be contaminated. B. Any partially uncovered sterile package need not be considered contaminated. C. A commercially packaged surgical item is not considered sterile if past expiration date. D. Sterility may not be preserved even when one sterile item touches another sterile item.

C. A commercially packaged surgical item is not considered sterile if past expiration date.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? A. Ask the client how the bag is changed. B. Determine the necessity of the bag change. C. Ask a skilled nurse to assist with the procedure. D. Read the policy and procedure manual.

C. Ask a skilled nurse to assist with the procedure.

Which of the following are considered the building blocks of the immune system? A. Red blood cells B. Macrophages C. T lymphocytes D. Macrocytes

C. T lymphocytes

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? A. The nurse should notify the primary care provider about the bruises. B. The nurse should request permission from the client to photograph the bruises. C. The nurse should question the client about the source of the bruises. D. The nurse should contact the facility's social services department.

C. The nurse should question the client about the source of the bruises.

Which parties are essential for the nurse to include in the implementation of a client's plan of care? A. Client, physical therapist, and nursing staff B. Client, surgeon, and health care provider C. Client, health care provider, and hospital director D. Client, family, and health care provider

D. Client, family, and health care provider

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? A. Shigella in the intestinal tract B. Escherichia coli in the urinary tract C. Shigella in the urinary tract D. Escherichia coli in the intestinal tract

D. Escherichia coli in the intestinal tract

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? A. Notify the health care provider that the client has required pain medications. B. Instruct the client that pain medication is available at regular intervals. C. Perform additional nonpharmacological pain interventions. D. Reassess the client to determine the effectiveness of the interventions.

D. Reassess the client to determine the effectiveness of the interventions.

Which mask should the nurse don when caring for a client with tuberculosis? A. Low-efficiency particulate air (LEPA) B. Filtered respirator C. No mask is needed D. Surgical mask

B. Filtered respirator

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?

Inform client what to expect after surgery