EAQ

Which client being triaged during a disaster would the nurse classify as emergency severity level 2 (ESI-2) using the Emergency Severity Index? Select all that apply. One, some, or all responses may be correct. 1 Client experiencing cardiac arrest 2 Client in severe respiratory distress 3 Client with chest pain from ischemia 4 Client experiencing bradypnea postoverdose 5 Client with multiple trauma who is responsive

1 Client experiencing cardiac arrest 2 Client in severe respiratory distress Correct 3 Client with chest pain from ischemia 4 Client experiencing bradypnea postoverdose 5 Client with multiple trauma who is responsive A client experiencing chest pain with ischemia would be classified as ESI-2. Clients experiencing cardiac arrest, severe respiratory distress, and bradypnea postoverdose would be classified as ESI-1. A client with multiple trauma who is unresponsive would be classified as ESI-2.

Which action would the nurse take to prevent aspiration recurrence in a client with aspiration pneumonia who is NPO status with a nasogastric tube and a prescription for antibiotics? Select all that apply. One, some, or all responses may be correct. 1 Obtaining vital signs after feedings 2 Administering intravenous antibiotics 3 Elevating the head of the bed to 30 degrees 4 Determining residual every 4 hours 5 Assessing for the gag reflex before feeding

1 Obtaining vital signs after feedings 2 Administering intravenous antibiotics Correct 3 Elevating the head of the bed to 30 degrees 4 Determining residual every 4 hours 5 Assessing for the gag reflex before feeding The nurse would elevate the head of the bed a minimum of 30 degrees to prevent aspiration of tube feedings in a client with a nasogastric tube. Obtaining vital signs after tube feedings would not prevent aspiration. Intravenous antibiotics would be administered to treat the current pneumonia but would not prevent aspiration recurrence. Determining residual every 4 hours would assess the client's tolerance of tube feedings but would not prevent aspiration. The client's gag reflex would not need to be assessed because the client is NPO status.

Which nursing action occurring within a recently implemented falls reduction program indicates the need for additional staff education? Select all that apply. One, some, or all responses may be correct. 1 Using gait belts for client transfers and ambulation 2 Placing a bedside commode for a client experiencing incontinence 3 Establishing an elimination schedule for clients experiencing confusion 4 Placing a fall pad on the floor by the bed of a client with a high risk for falls 5 Stabilizing a client with hypotension in a standing position for 5 minutes before ambulatin

1 Using gait belts for client transfers and ambulation 2 Placing a bedside commode for a client experiencing incontinence 3 Establishing an elimination schedule for clients experiencing confusion 4 Placing a fall pad on the floor by the bed of a client with a high risk for falls Correct 5 Stabilizing a client with hypotension in a standing position for 5 minutes before ambulating Clients experiencing hypotension should dangle on the side of the bed for 5 minutes before ambulation. Fall risk reduction programs include using gait belts for transfers and ambulation, using bedside commodes, establishing an elimination schedule, and placing fall pads

A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client? 1 Oral hydroxyurea 2 Vitamin B12 injections 3 Oral iron supplements 4 Erythropoietin injections

2 Vitamin B12 injections

A client with coronary artery disease and a recent diagnosis of venous thrombosis calls the outpatient clinic to report sudden onset of shortness of breath. Which action by the nurse is best? 1 Suggest that the client call 911. 2 Have the client take slow, deep breaths. 3 Schedule the client to be seen in the clinic in 1 hour. 4 Have the client take a low dose aspirin tablet immediately.

A client with coronary artery disease and a recent diagnosis of venous thrombosis calls the outpatient clinic to report sudden onset of shortness of breath. Which action by the nurse is best? Correct1 Suggest that the client call 911. 2 Have the client take slow, deep breaths. 3 Schedule the client to be seen in the clinic in 1 hour. 4 Have the client take a low dose aspirin tablet immediately. The client's history and symptom of sudden onset dyspnea could be associated with multiple critical diagnoses (such as acute coronary syndrome or pulmonary embolism), which require rapid evaluation and treatment in the emergency department. Because the client has the potential for life-threatening diagnoses, encouragement of deep breathing is not an adequate response. The client needs immediate evaluation and possible intervention, so scheduling an appointment in an hour is not sufficient. Although the client may be experiencing acute coronary syndrome, there has been inadequate assessment of the etiology of the dyspnea, so taking an aspirin is not indicated.

According to Benner , the nurse passes through five levels of proficiency when acquiring and developing generalized or specialized nursing skills. Arrange the order of level of proficiency from lowest to highest. 1.Expert 2.Proficient 3.Competent 4.Advanced beginner 5.Novice

According to Benner , the nurse passes through five levels of proficiency when acquiring and developing generalized or specialized nursing skills. Arrange the order of level of proficiency from lowest to highest. 1.Novice 2.Advanced beginner 3.Competent 4.Proficient 5.Expert

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Which describes the nurse's responsibility in this situation? 1 The nurse's judgment was adequate, and the client was treated accordingly. 2 The possibility of tetanus was not foreseen because the client was immunized. 3 Nurses would routinely administer immunization against tetanus after such an injury. 4 Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Which describes the nurse's responsibility in this situation? 1 The nurse's judgment was adequate, and the client was treated accordingly. 2 The possibility of tetanus was not foreseen because the client was immunized. 3 Nurses would routinely administer immunization against tetanus after such an injury. Correct4 Assessment by the nurse was incomplete and, as a result, the treatment was insufficient. The nurse's data collection was not adequate because the nurse did not ask about the date of the previous tetanus inoculation. The nurse failed to support the life and well-being of a client. The nurse's assessment was not thorough in regard to determining the date of immunization. It was essential to determine when the client was last immunized; for a "tetanus-prone" wound, like a puncture from a rusty nail, some form of tetanus immunization usually is given. Administering immunization against tetanus is not an independent function of the nurse.Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.

How would the nurse incorporate the quality of accuracy into client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each client's activity 3 By providing complete and appropriate information in each client's record 4 By recording descriptive and objective information that he or she sees, hears, feels, and smells

How would the nurse incorporate the quality of accuracy into client documentation? 1 By providing a logical order for the communication Correct2 By using exact measurements for each client's activity 3 By providing complete and appropriate information in each client's record 4 By recording descriptive and objective information that he or she sees, hears, feels, and smells The use of exact measurements establishes accuracy. The nurse follows the principle of organization by communicating the information in a logical order. The nurse incorporates the guideline of completion by providing a complete and appropriate record with all the essential information. A factual record contains descriptive and objective information about what the nurse sees, hears, feels, and smells.

In addition to the regular pregnancy diet and prenatal vitamins and minerals, which supplements may be needed by a pregnant client with rheumatic heart disease? Select all that apply. One, some, or all responses may be correct. 1 Iron 2 Calcium 3 Folic acid 4 Vitamin C 5 Vitamin B12

In addition to the regular pregnancy diet and prenatal vitamins and minerals, which supplements may be needed by a pregnant client with rheumatic heart disease? Select all that apply. One, some, or all responses may be correct. Correct1 Iron 2 Calcium Correct3 Folic acid 4 Vitamin C 5 Vitamin B12

The emergency department nurse would provide immediate care based on priority to the client with which condition? 1 Second-degree burns 2 Blunt abdominal trauma 3 Closed fracture of the right arm 4 Repeated tonic-clonic seizures

The emergency department nurse would provide immediate care based on priority to the client with which condition? 1 Second-degree burns 2 Blunt abdominal trauma 3 Closed fracture of the right arm Correct4 Repeated tonic-clonic seizures The client with tonic-clonic seizures may experience severe muscle contractions, which is a life-threatening complication. This client should be provided with immediate care. Clients with second-degree burns should be given second priority of care because their conditions may worsen if treatment is not provided as early as possible. Blunt abdominal trauma can be a serious condition if internal bleeding is found, but still does not require as immediate care as the seizures. Clients with closed arm fractures can be provided with care later, depending on the other clients in the emergency department.

The nurse is learning about the rules of leaders. Which actions of the nurse indicate effective implementation of these rules? Select all that apply. One, some, or all responses may be correct. 1 Communicating in a simple language with followers 2 Giving an opportunity to the followers to express their views 3 Instructing followers to decide the actions to be performed 4 Avoiding communicating clear boundaries with followers 5 Ensuring proper eye contact while communicating with followers

The nurse is learning about the rules of leaders. Which actions of the nurse indicate effective implementation of these rules? Select all that apply. One, some, or all responses may be correct. Correct1 Communicating in a simple language with followers Correct2 Giving an opportunity to the followers to express their views 3 Instructing followers to decide the actions to be performed 4 Avoiding communicating clear boundaries with followers Correct5 Ensuring proper eye contact while communicating with followers An effective leader would use the simplest and fastest method to communicate with followers. An effective leader would give a chance to the followers to express their views, because followers have many questions to ask. Proper eye contact ensures effective communication; therefore, an effective leader would maintain proper eye contact while communicating with followers. An effective leader would use critical thinking to decide the actions to be performed but should not instruct the followers. An effective leader would communicate clear boundaries with followers.

When a client with heart failure reports sudden dyspnea and has bilateral crackles throughout the lungs with a respiratory rate of 32 breaths/minute, which action would the nurse take first? 1 Elevate the head of the bed to 75 degrees. 2 Obtain the apical pulse and blood pressure. 3 Notify the hospital Rapid Response Team. 4 Check oxygen saturation with the pulse oximeter.

When a client with heart failure reports sudden dyspnea and has bilateral crackles throughout the lungs with a respiratory rate of 32 breaths/minute, which action would the nurse take first? Correct1 Elevate the head of the bed to 75 degrees. 2 Obtain the apical pulse and blood pressure. 3 Notify the hospital Rapid Response Team. 4 Check oxygen saturation with the pulse oximeter. The client's history and symptoms suggest pulmonary edema. The nurse's first action would be to attempt to improve oxygenation and decrease the client's dyspnea by elevating the head of the bed, which will make it easier to take deep breaths and will also decrease venous return and reduce ventricular preload. The other actions are also appropriate after the client's head is elevated. Tachycardia and hypotension typically occur with pulmonary edema because of poor cardiac output and the nurse will monitor pulse and blood pressure frequently to evaluate response to treatment. The Rapid Response Team would be notified to have appropriate team members available to care for this critically ill client. Monitoring of oxygen saturation is needed to evaluate the client's response to treatment.

Which are the characteristics of the genital stage according to Freud's psychoanalytical model of personality development? Select all that apply. One, some, or all responses may be correct. 1 The focus of pleasure changes to the anal zone. 2 Sexual urges are directed outside the family circle. 3 Unresolved sexual conflicts resurface during this stage. 4 An individual may resolve the sexual conflicts at this stage. 5 Sexual urges from the oedipal stage are repressed and channeled productively.

Which are the characteristics of the genital stage according to Freud's psychoanalytical model of personality development? Select all that apply. One, some, or all responses may be correct. 1 The focus of pleasure changes to the anal zone. Correct2 Sexual urges are directed outside the family circle. Correct3 Unresolved sexual conflicts resurface during this stage. Correct4 An individual may resolve the sexual conflicts at this stage. 5 Sexual urges from the oedipal stage are repressed and channeled productively. According to Freud's psychoanalytical model of personality development, an individual passes through five stages of psychosexual development. The last stage is the genital stage, which lasts from puberty to adulthood. At this stage, sexual urges are reawakened and directed toward people outside the family circle. In the adolescent period, previous unresolved sexual conflicts resurface. An individual may resolve these conflicts at this stage. Upon reaching the anal stage, the focus of a child's pleasure shifts to the anal area. When an individual reaches the anal stage, sexual urges from the oedipal stage are repressed and channeled into productive activities that are socially acceptable.

Which client would the nurse suspect as being in the secondary stage of syphilis? 1 Client 1 2 Client 2 3 Client 3 4 Client 4

Which client would the nurse suspect as being in the secondary stage of syphilis? 1 Client 1 2 Client 2 Correct3 Client 3 4 Client 4 The nurse suspects client 3 is in the secondary stage of syphilis. Syphilis is a sexually transmitted disease caused by Treponema pallidum. Secondary syphilis develops 6 weeks to 6 months after the onset of primary syphilis. The symptoms of secondary syphilis are pustules, scaly psoriasis-like lesions, or gray-white wartlike lesions. The nurse suspects client 1, with chancres in the mouth, is in the primary stage of syphilis; client 2, with benign lesions (gummas) of the skin, is in the tertiary or last stage of syphilis; and client 4, with a painless, smooth, weeping lesion, is suspected to be in the primary stage of syphilis.

Which might an individual experience in Erikson's initiative versus guilt stage? Select all that apply. One, some, or all responses may be correct. 1 Pretends and tries out new roles 2 May develop a superego or a conscience 3 Thrives on his/her accomplishments and praise 4 May develop his/her autonomy by making choices 5 Fantasizes and imagines discovering the environment

Which might an individual experience in Erikson's initiative versus guilt stage? Select all that apply. One, some, or all responses may be correct. Correct1 Pretends and tries out new roles Correct2 May develop a superego or a conscience 3 Thrives on his/her accomplishments and praise 4 May develop his/her autonomy by making choices Correct5 Fantasizes and imagines discovering the environment

Which points about theories made by the nursing student are accurate? Select all that apply. One, some, or all responses may be correct. 1 A discipline constitutes a major portion of the knowledge of a theory. 2 A nursing theory helps identify the focus, means, and goals of practice. 3 Theories give a perspective to assess the situation of a client and to organize data and methods for analyzing and interpreting information. 4 Theory and scientific inquiry do not go hand in hand because they fail to provide guidelines for decision-making, problem-solving, and nursing interventions. 5 Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions.

Which points about theories made by the nursing student are accurate? Select all that apply. One, some, or all responses may be correct. 1 A discipline constitutes a major portion of the knowledge of a theory. Correct2 A nursing theory helps identify the focus, means, and goals of practice. Correct3 Theories give a perspective to assess the situation of a client and to organize data and methods for analyzing and interpreting information. 4 Theory and scientific inquiry do not go hand in hand because they fail to provide guidelines for decision-making, problem-solving, and nursing interventions. Correct5 Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions. A nursing theory helps identify the focus, means, and goals of practice. Theories give a perspective for assessing clients' situations and organizing data and methods for analyzing and interpreting information. Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions. A theory constitutes much of the knowledge of a discipline. Theory and scientific inquiry are vital links to one another, providing guidelines for decision-making, problem-solving, and nursing interventions.

Which response will the nurse manager use after overhearing a conversation between a nurse and a client that is focused on the details of their impending divorces? 1 Wait until the conversation ends and then tell the nurse that such topics must be discussed in strict privacy to ensure client confidentiality. 2 Immediately ask to speak to the nurse privately and state that sharing such personal information is nontherapeutic and not acceptable. 3 Immediately explain to both nurse and client that such conversations are inappropriate and that the nurse's assignment will be changed. 4 Wait until shift report and use the opportunity to discuss appropriate nurse-client boundaries with the attending nursing staff.

Which response will the nurse manager use after overhearing a conversation between a nurse and a client that is focused on the details of their impending divorces? 1 Wait until the conversation ends and then tell the nurse that such topics must be discussed in strict privacy to ensure client confidentiality. Correct2 Immediately ask to speak to the nurse privately and state that sharing such personal information is nontherapeutic and not acceptable. 3 Immediately explain to both nurse and client that such conversations are inappropriate and that the nurse's assignment will be changed. 4 Wait until shift report and use the opportunity to discuss appropriate nurse-client boundaries with the attending nursing staff. The nurse-client relationship should always remain client focused. Discussing personal issues with the client, even sharing similar experiences, is nontherapeutic and should be discussed immediately by the nurse's supervisor. The supervisor would also point out that any conversation that is overheard violates confidentiality and privacy. The nurse's management of the nurse-client relationship should be discussed privately, and it may not be necessary to change the assignment. Nurse-client boundaries could be an in-service topic, but this specific incident does not need to be shared with the entire staff.

Which statements listed by the nursing student are appropriate regarding theories related to temperament? Select all that apply. One, some, or all responses may be correct. 1 An easy child is open and adaptable to changes. 2 A difficult child requires a more structured environment. 3 A difficult child shows an intense and primarily negative mood. 4 A slow-to-warm up child displays a mild to moderately intense mood.

Which statements listed by the nursing student are appropriate regarding theories related to temperament? Select all that apply. One, some, or all responses may be correct. Correct1 An easy child is open and adaptable to changes. Correct2 A difficult child requires a more structured environment. Correct3 A difficult child shows an intense and primarily negative mood. 4 A slow-to-warm up child displays a mild to moderately intense mood. 5 A difficult child reacts negatively and with mild intensity to new stimuli.

Which term describes the nurse encouraging the shy client to ask questions after the nurse explains a procedure to the client? 1 Fairness 2 Discipline 3 Confidence 4 Perseverance

Which term describes the nurse encouraging the shy client to ask questions after the nurse explains a procedure to the client? 1 Fairness 2 Discipline Correct3 Confidence 4 Perseverance Encouraging the client to ask questions is an example of confidence on the part of the nurse. This attitude allows the nurse to communicate freely with the client and to perform procedures that may be complex. Listening to both sides when an issue arises between staff and a client or family is an example of fairness. Examples of discipline include evaluating the evidence and taking the time to thoroughly understand a situation. Clarifying a situation that is provoking doubt on the part of a nurse is an example of perseverance. Test-Taking Tip: Look for answers that focus on the client or that are directed toward feelings.

The nurse is preparing to administer medications to four different newborns to treat infections. Which newborn would the nurse identify as likely to develop Gray syndrome? 1 Newborn 1 2 Newborn 2 3 Newborn 3 4 Newborn 4

chloramphenicol

clotrimazole

treats fungal infections like Candidiasis

Which nursing-sensitive indicator can be used to evaluate the process of nursing care? Select all that apply. One, some, or all responses may be correct. 1 Client falls 2 Pressure ulcers 3 Nurse job satisfaction 4 Supply of nursing staff 5 Skill level of nursing staff

1 Client falls 2 Pressure ulcers Correct3 Nurse job satisfaction 4 Supply of nursing staff 5 Skill level of nursing staff Nursing-sensitive indicators reflect the structure, process, and outcomes of nursing care. Job satisfaction can be used to evaluate the process of nursing care. Client falls and pressure ulcers reflect care outcomes. Supply and skill level of nursing staff can be used to evaluate the nursing care structure.

Which client is at an increased risk for hospital-acquired pneumonia? Select all that apply. One, some, or all responses may be correct. 1 Client who was admitted yesterday with hypoxia and fever 2 Client who has been on mechanical ventilation for 5 days 3 Client who reports being on an airplane with other sick individuals 4 Client who presents to the emergency department with cough and crackles 5 Client who was admitted to the hospital 5 days ago for abdominal pain

1 Client who was admitted yesterday with hypoxia and fever 2 Client who has been on mechanical ventilation for 5 days 3 Client who reports being on an airplane with other sick individuals 4 Client who presents to the emergency department with cough and crackles Correct 5 Client who was admitted to the hospital 5 days ago for abdominal pain Hospital-acquired pneumonia occurs in nonintubated clients and begins 48 hours after admission. A client admitted 5 days ago with abdominal pain would meet the criteria and is at increased risk for hospital-acquired pneumonia. A client admitted the previous day has not been in the hospital at least 48 hours. A client on mechanical ventilation is intubated and does not meet the criteria for hospital-acquired pneumonia. A client who has been on an airplane with other ill individuals would be at risk for community-acquired pneumonia. A client in the emergency department has not been admitted to the hospital.Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

Which action by nursing staff during a facility fire drill requires correction? Select all that apply. One, some, or all responses may be correct. 1 Directing ambulatory clients to walk to a safe area 2 Discontinuing oxygen for all clients able to breathe without it 3 Closing all doors and windows after clients are safely removed 4 Use of an ABC extinguisher to put out a small trash can fire before evacuation 5 Asking the ambulatory clients to help evacuate several wheelchair-bound clients

1 Directing ambulatory clients to walk to a safe area 2 Discontinuing oxygen for all clients able to breathe without it 3 Closing all doors and windows after clients are safely removed Correct 4 Use of an ABC extinguisher to put out a small trash can fire before evacuation 5 Asking the ambulatory clients to help evacuate several wheelchair-bound clients All clients should be safely removed before attempting to extinguish a fire. Directing ambulatory clients to walk to a safe area, discontinuing oxygen for those who can breathe without it, closing all doors and windows after safely removing clients, and asking ambulatory clients to help evacuate wheelchair-bound clients are all appropriate staff responses during a fire drill.

Which sign or symptom would the nurse expect to find on assessment of a client with a blood glucose level of 55 mg/dL? Select all that apply. One, some, or all responses may be correct. 1 Increased thirst 2 Abdominal pain 3 Frequent urination 4 Cold, clammy skin 5 3+ glucose in urinalysis

1 Increased thirst 2 Abdominal pain 3 Frequent urination Correct 4 Cold, clammy skin 5 3+ glucose in urinalysis A client with a blood glucose level of 55 mg/dL indicates hypoglycemia. Clinical manifestations would include cold, clammy skin; tachycardia; nervousness; and slurred speech. A client with hyperglycemia would present with increased thirst (polydipsia), abdominal pain, increased urination (polyuria), and polyphagia. The client with hyperglycemia would have glycosuria.

Which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%? Select all that apply. One, some, or all responses may be correct. 1 Level of orientation 2 Arterial blood gases 3 Bilateral lung sounds 4 Complete blood count 5 Pulmonary function test

1 Level of orientation Correct 2 Arterial blood gases 3 Bilateral lung sounds 4 Complete blood count 5 Pulmonary function test Clients with COPD who have low oxygen levels respond to oxygen administration. However, some clients with COPD have a respiratory drive that stimulates breathing that is dependent on carbon dioxide. The administration of too much oxygen in these clients lowers respiratory drive and decreases breathing. Therefore, the nurse would assess the client's arterial blood gases to determine how much oxygen to administer. Level of orientation shows the amount of hypoxia the client is experiencing. Clients may have abnormal lung sounds that can impede oxygenation, but this is not the basis for determining oxygen administration. A complete blood count assesses red blood cells, hemoglobin, and hematocrit; these values can be diminished in clients with COPD, but they do not determine oxygen needs. Pulmonary function tests are used to diagnose pulmonary disorders.

Which statement reflects a pairing approach to delegation of registered nurse (RN) and nursing assistive personnel (NAP) assignments? Select all that apply. One, some, or all responses may be correct. 1 NAP serves the unit and has minimal RN direction. 2 RN and NAP are consistently scheduled to work together. 3 NAP works from a task list as outlined in the job description. 4 RN is recognized as having the authority to make the delegation decisions. 5 RN and NAP only provide care together for a given set of clients during a given shift.

1 NAP serves the unit and has minimal RN direction. 2 RN and NAP are consistently scheduled to work together. 3 NAP works from a task list as outlined in the job description. 4 RN is recognized as having the authority to make the delegation decisions. Correct 5 RN and NAP only provide care together for a given set of clients during a given shift A pairing approach involves the RN and NAP working together only during a given shift; they are not intentionally scheduled together consistently. In a unit-based scenario, NAP serve the unit overall and interact minimally with the RN. Assignment of a RN and NAP to the same schedule reflects a partnering approach. Having NAPs work from a specific task list as outlined in the job description is characteristic of a unit-based approach. In the partnering approach, the RN is recognized as having the authority to make the delegation decisions.

Which organization provides scope and practice guidelines on the roles and responsibilities for nursing and nursing specialties? Select all that apply. One, some, or all responses may be correct. 1 State Nursing Association 2 National League of Nursing 3 American Nurses Association 4 Academy of Medical Surgical Nurses 5 Quality and Safety Education for Nurses

1 State Nursing Association 2 National League of Nursing Correct 3 American Nurses Association 4 Academy of Medical Surgical Nurses 5 Quality and Safety Education for Nurses The American Nurses Association develops and publishes scope and standards of practice guidelines for nursing and nursing specialties. Many professional organizations have state-level nursing associations, but they do not publish standards and scope of practice. The National League of Nursing is a professional organization related to the education of nurses. The Academy of Medical Surgical Nurses publishes scope and standards of practice for general medical surgical nursing, but not nursing and nursing specialties. Quality and Safety Education for Nurses supports development of the knowledge, skills, and attitudes needed to improve the quality and safety of the health care system.

Which data would the nurse document for a client who returns to the clinic with induration of the skin 48 hours after receiving a purified protein derivative (PPD) test? Select all that apply. One, some, or all responses may be correct. 1 The client has active tuberculosis (TB). 2 The client has received a PPD in the past. 3 The client has been exposed to tuberculosis. 4 The client has an allergic reaction to the test. 5 The client has a decreased immune response.

1 The client has active tuberculosis (TB). 2 The client has received a PPD in the past. Correct 3 The client has been exposed to tuberculosis. 4 The client has an allergic reaction to the test. 5 The client has a decreased immune response. A positive PPD indicates that the client has been exposed to TB and developed antibodies to the bacteria, and the nurse would document that the client has been exposed to TB. Active TB must be diagnosed with a positive sputum culture. Clients may receive annual PPDs and never have a positive reaction. An allergic reaction to the PPD test would cause redness at the injection site. Decreased immunity puts the client at risk for contracting TB, but a decreased immune response would not cause a positive result.

Which intervention would the nurse include in the plan of care for a client with breast cancer who received doxorubicin and cyclophosphamide 12 days ago and now has a white blood cell (WBC) count of 1.4 cells/mm 3 and reports shortness of breath and activity intolerance? Select all that apply. One, some, or all responses may be correct. 1 Use an electric razor when shaving. 2 Institute neutropenic precautions. 3 Place client on airborne precautions. 4 Transfuse two units of packed red blood cells (RBCs). 5 Instruct nursing staff to wear a dosimeter badge.

1 Use an electric razor when shaving. Correct 2 Institute neutropenic precautions. 3 Place client on airborne precautions. 4 Transfuse two units of packed red blood cells (RBCs). 5 Instruct nursing staff to wear a dosimeter badge Doxorubicin and cyclophosphamide can lower the client's blood cell counts. Clients with low WBC counts need interventions to prevent infection, which include instituting neutropenic precautions. The nurse would instruct the client to use an electric razor if the platelet count was less than 50,000 cells/µL. Airborne precautions would be indicated if the client was ill with an infectious disease. The nurse would transfuse RBCs for a client with anemia (if prescribed by the health care provider). Nursing staff would wear dosimeter badges when caring for a client receiving internal radiation (brachytherapy).Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) read each answer thoroughly and see if it completely covers the material asked by the question; and (3) narrow the choices by immediately eliminating answers you know are incorrect.

A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action would the nurse take to prepare for the arrival of the client? 1 Reserve an operating room. 2 Organize equipment for a tracheotomy. 3 Prepare equipment for chest tube insertion. 4 Arrange for a portable chest x-ray examination.

A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action would the nurse take to prepare for the arrival of the client? 1 Reserve an operating room. 2 Organize equipment for a tracheotomy. Correct3 Prepare equipment for chest tube insertion. 4 Arrange for a portable chest x-ray examination. The priority is to reinflate the lungs and stabilize the client's respiratory status. Reserving an operating room may be necessary later but is premature at this time. Organizing equipment for a tracheotomy is unnecessary; an endotracheal tube should be used for maintenance of the airway if necessary. Arranging for a portable chest x-ray examination is not the priority at this time; this may be done later.

A client reports fever, cough, muscle aches, night sweats, and chest pain. The client's laboratory report indicates the presence of Coccidioides organisms in the respiratory tract. Which medication would the nurse anticipate administering to this client? 1 Oseltamivir 2 Fluconazole 3 Pyrazinamide 4 Cephalosporin

A client reports fever, cough, muscle aches, night sweats, and chest pain. The client's laboratory report indicates the presence of Coccidioides organisms in the respiratory tract. Which medication would the nurse anticipate administering to this client? 1 Oseltamivir Correct2 Fluconazole 3 Pyrazinamide 4 Cephalosporin Coccidioides organisms cause coccidioidomycosis. The symptoms of coccidioidomycosis are fever, cough, muscle aches, night sweats, and chest pain. Fluconazole is an antifungal medication beneficial in treating coccidioidomycosis. Oseltamivir is an antiviral medication used to treat influenza. Pyrazinamide is an antitubercular medication, used to treat tuberculosis. Cephalosporin is an antibiotic and may be used in treatment of bacterial pharyngitis.

A client throws a chair and starts screaming at the other clients, who become frightened, upset, and anxious. After the agitated client is removed, which action would the nurse take? 1 Continue the unit's activities as if nothing has happened. 2 Arrange a unit meeting to discuss what has just happened. 3 Refocus clients' negative comments to more positive topics. 4 Have a private talk with the clients who became frightened.

A client throws a chair and starts screaming at the other clients, who become frightened, upset, and anxious. After the agitated client is removed, which action would the nurse take? 1 Continue the unit's activities as if nothing has happened. Correct2 Arrange a unit meeting to discuss what has just happened. 3 Refocus clients' negative comments to more positive topics. 4 Have a private talk with the clients who became frightened. This type of incident affects everyone, so arranging a unit meeting provides an opportunity for the other clients to voice and share feelings and to identify and separate real from imaginary fears. An open expression of feelings allows the nurse to address clients' fears and provide reassurance. Ignoring the situation denies reality and may precipitate or reinforce feelings of vulnerability and fear in the other clients. Refocusing clients denies concerns and could increase anxiety and fear. Having a private talk with clients neglects the needs of the whole unit.

After conducting a falls risk assessment education session for the staff and observing falls risk assessment on the unit, which staff action needs review for correction? 1 Using a fall risk assessment tool 2 Assessing the environment for fall hazards 3 Inquiring about the client's history of falls 4 Delegating falls assessment to assistive personnel

After conducting a falls risk assessment education session for the staff and observing falls risk assessment on the unit, which staff action needs review for correction? 1 Using a fall risk assessment tool 2 Assessing the environment for fall hazards 3 Inquiring about the client's history of falls Correct4 Delegating falls assessment to assistive personnel Falls risk cannot be delegated. The nurse needs to be the person to complete falls risk assessment, not assistive personnel. Use of a falls risk assessment tool, assessing the environment for hazards, and exploring the client's history of falls are all appropriate actions for fall risk assessment. Topics Client Needs - Safety and Infection Contr

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct. 1 Mold 2 Cold air 3 Pet dander 4 Air pollution 5 Cigarette smoke

Correct 1 Mold Correct 2 Cold air Correct 3 Pet dander Correct 4 Air pollution Correct 5 Cigarette smoke Clients with asthma should be instructed to avoid asthma attack triggers such as mold, cold air, pet dander, air pollution, and cigarette smoke.

Which intervention related to restraint use is appropriate to delegate to nursing assistive personnel (NAP)? Select all that apply. One, some, or all responses may be correct. 1 Appropriate use of restraints 2 Determination of the need for restraints 3 Assessment of the client's behavior 4 Routine checks of the client while in restraints 5 Orientation of the client to the environment

Appropriate use of restraints 2 Determination of the need for restraints 3 Assessment of the client's behavior Correct 4 Routine checks of the client while in restraints 5 Orientation of the client to the environment NAP can perform routine checks of the client in restraints. Determination of appropriate use of restraints and the need for restraints; assessment of a client's behavior; and orientation of the client to the environment are not tasks that can be delegated to NAP

Which manifestation is an adverse effect of intravenous lorazepam? Select all that apply. One, some, or all responses may be correct. 1 Amnesia 2 Drowsiness 3 Sleep driving 4 Blurred vision 5 Respiratory depression

Correct 1 Amnesia Correct 2 Drowsiness Correct 3 Sleep driving Correct 4 Blurred vision Correct 5 Respiratory depression Benzodiazepines such as lorazepam have a range of side effects, many of which are related to central nervous system depression. Anterograde amnesia, drowsiness, sleep driving, blurred vision, and respiratory depression are all potential adverse effects of lorazepam.

Which factor would the nurse consider when setting priorities for care during a shift? Select all that apply. One, some, or all responses may be correct. 1 Client acuity 2 Unit organization 3 Availability of resources 4 Own experience and expertise 5 Philosophies and models of care

Correct 1 Client acuity Correct 2 Unit organization Correct 3 Availability of resources Correct 4 Own experience and expertise Correct 5 Philosophies and models of care When setting priorities for care, the nurse must consider client acuity, organization of the unit, assessment of available resources, recognition of own experience and expertise, and an understanding of care philosophies and models of care used on the unit.

Which step of the problem-solving process would be most important for the nurse to consider when addressing a recent increase in client falls on the unit? Select all that apply. One, some, or all responses may be correct. 1 Collecting recent data concerning the falls to clearly identify the problem 2 Analyzing data collected to identify solutions to address issues contributing to falls 3 Identifying risks and consequences of possible solutions to decrease falls on the unit 4 Considering how one's own beliefs concerning causes of the recent increase may affect solutions 5 Establishing criteria to determine if implementation of a fall safety training program is effective

Correct 1 Collecting recent data concerning the falls to clearly identify the problem 2 Analyzing data collected to identify solutions to address issues contributing to falls 3 Identifying risks and consequences of possible solutions to decrease falls on the unit 4 Considering how one's own beliefs concerning causes of the recent increase may affect solutions 5 Establishing criteria to determine if implementation of a fall safety training program is effective To adequately address the underlying causes of a problem, the problem must first be clearly identified. For the nurse working to address an increase in client falls on the unit, the most important part of the problem-solving process would be to collect data about the falls to help clearly identify the problem. Analyzing data, identifying the possible outcomes for solutions, considering how one's own beliefs may affect the solution choice, and establishing evaluation criteria are also necessary steps in the problem-solving process, but clearly identifying the problem is the most important step.

Which action using the scientific method would the nurse use to identify nursing factors affecting adherence of diabetic clients who have been transitioned back to the community after hospitalization? Select all that apply. One, some, or all responses may be correct. 1 Discussing whether nursing factors are associated with difficulty managing diabetes after the return home 2 Analyzing national and local level data concerning nursing factors and client adherence outcomes for newly diagnosed diabetic clients 3 Hypothesizing that hospital nursing factors are related to client difficulties in adhering to a diabetic regimen on returning home 4 Reviewing the literature concerning the role of hospitals/nurses in transitioning clients newly diagnosed diabetic clients from hospital to home 5 Assessing results indicating that nursing factors such as short staffing are related to nonadherence issues of newly diagnosed diabetic

Correct 1 Discussing whether nursing factors are associated with difficulty managing diabetes after the return home Correct 2 Analyzing national and local level data concerning nursing factors and client adherence outcomes for newly diagnosed diabetic clients Correct 3 Hypothesizing that hospital nursing factors are related to client difficulties in adhering to a diabetic regimen on returning home Correct 4 Reviewing the literature concerning the role of hospitals/nurses in transitioning clients newly diagnosed diabetic clients from hospital to home Correct 5 Assessing results indicating that nursing factors such as short staffing are related to nonadherence issues of newly diagnosed diabetic clients Discussing whether nursing factors are associated with difficulties managing diabetes helps identify the problem, which is the first step of the scientific method. Analysis of local and national level data reflects the fourth step, which tests the hypothesis or question. The third step is to develop a hypothesis or proposed explanation made based on limited evidence; this serves as a starting point for the investigation. A review of the literature supports data collection, which is the fourth step of the scientific method. The final step includes evaluation of results of the study, which indicate that short staffing contributes to adherence issues for these clients.

Which infection requires airborne precautions? Select all that apply. One, some, or all responses may be correct. 1 Measles 2 Influenza 3 Clostridium difficile 4 Bacterial meningitis 5 Methicillin-resistant Staphylococcus aureus (MRSA)

Correct 1 Measles 2 Influenza 3 Clostridium difficile 4 Bacterial meningitis 5 Methicillin-resistant Staphylococcus aureus (MRSA) Varicella, measles, and tuberculosis require airborne precautions because these infections spread through small particles in the air. Droplet precautions are implemented to prevent the spread of influenza and bacterial meningitis. C. difficile and MRSA require the use of contact precautions.

Which intervention would the nurse include in the plan of care for a client being treated with lithium for bipolar disorder? Select all that apply. One, some, or all responses may be correct. 1 Monitoring blood levels 2 Assessing for slurred speech 3 Evaluating intake and output 4 Instructing the client to limit caffeine intake 5 Advising the client to use reliable birth control

Correct 1 Monitoring blood levels Correct 2 Assessing for slurred speech Correct 3 Evaluating intake and output Correct 4 Instructing the client to limit caffeine intake Correct 5 Advising the client to use reliable birth control

Which action would the nurse include in the plan of care to prevent oral infections in a client preparing to undergo surgical resection for esophageal cancer? Select all that apply. One, some, or all responses may be correct. 1 Soaking dentures every night 2 Providing Yankauer suctioning 3 Swishing and spitting with chlorhexidine 4 Administering intravenous (IV) fluids 5 Offering sugar-free candies to moisten the mouth

Correct 1 Soaking dentures every night Correct 2 Providing Yankauer suctioning Correct 3 Swishing and spitting with chlorhexidine Correct 4 Administering intravenous (IV) fluids Correct 5 Offering sugar-free candies to moisten the mouth Good oral care is essential for clients undergoing esophageal cancer resection to prevent infections of the oral cavity. The nurse would ensure that the client soaks the dentures every night to prevent food particles from causing irritation and infection. Yankauer suctioning helps the client remove excess secretions. Chlorhexidine is frequently used to decrease the incidence of oral infections. IV fluids promote good hydration, which lubricates the oral cavity. Sugar-free candy can also be used to keep the mouth moist.

Which nursing resource must be available to effectively meet potential needs during a disaster? Select all that apply. One, some, or all responses may be correct. 1 Staff 2 Medication 3 Hospital beds 4 Mechanical ventilators 5 Personal protective equipment

Correct 1 Staff Correct 2 Medication Correct 3 Hospital beds Correct 4 Mechanical ventilators Correct 5 Personal protective equipment Preparation for disasters includes ensuring resources are available to meet potential needs. The nurse leader must ensure there is adequate staff, medication, hospital beds, medical devices such as mechanical ventilators, and personal protective equipment available to address potential needs during a disaster.

Which factor supports task delegation to nursing assistive personnel (NAP) according to the National Council of State Boards of Nursing (NCSBN) Decision Tree? Select all that apply. One, some, or all responses may be correct. 1 The task is within the nurse's scope of practice. 2 The task may be performed with a predictable outcome. 3 Agency policies and protocols are available for the task or activity. 4 The task is performed according to an established sequence of steps. 5 NAP have the appropriate knowledge, skills, and abilities required to complete the task.

Correct 1 The task is within the nurse's scope of practice. Correct 2 The task may be performed with a predictable outcome. Correct 3 Agency policies and protocols are available for the task or activity. Correct 4 The task is performed according to an established sequence of steps. Correct 5 NAP have the appropriate knowledge, skills, and abilities required to complete the task. According to the NCSBN Decision Tree, for a task to be delegated it must be within the nurse's scope of practice and have a predictable outcome. Agency policies and procedures must be available for the task, and it must have an established sequence of steps. The NAP to whom the task is assigned must have the appropriate knowledge, skills, and abilities to perform the task.

Which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? Select all that apply. One, some, or all responses may be correct. 1 Weight 2 Inactivity 3 Cholesterol 4 Tobacco use 5 Homocysteine

Correct 1 Weight Correct 2 Inactivity Correct 3 Cholesterol Correct 4 Tobacco use Correct 5 Homocysteine Modifiable risk factors are those a person can change. Modifiable risk factors for cardiovascular disease include maintaining a healthy weight, getting regular physical activity, keeping cholesterol levels within normal limits, refraining from using tobacco, and monitoring homocysteine levels to make sure they are within the normal range.

The goal of a particular nursing theory is to use communication to help a client reestablish positive adaptation to the environment, and the framework for the nursing practice is based on treating nursing as a dynamic interpersonal process among the nurse, the client, and the health care system. Which nursing theory are these points related to? 1 King's theory 2 Neuman's theory 3 Nightingale's theory 4 Benner and Wrubel's theory

The goal of a particular nursing theory is to use communication to help a client reestablish positive adaptation to the environment, and the framework for the nursing practice is based on treating nursing as a dynamic interpersonal process among the nurse, the client, and the health care system. Which nursing theory are these points related to? Correct1 King's theory 2 Neuman's theory 3 Nightingale's theory 4 Benner and Wrubel's theory King's theory focuses on using communication to help the client reestablish positive adaptation to the environment; its framework for practice is based on treating nursing as a dynamic interpersonal process among the nurse, the client, and the health care system. Neuman's theory focuses on helping individuals, families, and groups attain and maintain a maximum level of total wellness by purposeful interventions. Nightingale's theory is based on facilitating the reparative processes of the body by manipulating a client's environment. Benner and Wrubel's theory focuses on a client's need for caring as a means of coping with the stressors of an illness.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The mechanism of action of maraviroc is represented by which statement? 1 It inhibits the insertion of viral DNA into the host cell's human DNA. 2 It prevents protease enzyme from cutting human immunodeficiency virus (HIV) into the proper length. 3 It blocks the C-C chemokine receptor type 5 (CCR5) receptor on CD4+ T cells. 4 It binds directly to the HIV-1 enzyme reverse transcriptase.

The mechanism of action of maraviroc is represented by which statement? 1 It inhibits the insertion of viral DNA into the host cell's human DNA. 2 It prevents protease enzyme from cutting human immunodeficiency virus (HIV) into the proper length. Correct3 It blocks the C-C chemokine receptor type 5 (CCR5) receptor on CD4+ T cells. 4 It binds directly to the HIV-1 enzyme reverse transcriptase. Entry inhibitors such as maraviroc act by blocking the CCR5 receptor on CD4+ T cells. Integrase inhibitors inhibit the insertion of viral DNA into the host cell's human DNA by inhibiting the HIV enzyme integrase. Protease inhibitors prevent the protease enzyme from cutting HIV proteins into the proper lengths. Non-nucleoside reverse transcriptase inhibitors act by binding directly to the HIV-1 enzyme reverse transcriptase.

The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that would be taken. 1.Institute respiratory isolation. 2.Insert an intravenous access device. 3.Assist with a lumbar puncture. 4.Administer the prescribed antibiotics. 5.Monitor for signs of increased intracranial pressure (ICP).

The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that would be taken. Correct1.Institute respiratory isolation. Correct2.Insert an intravenous access device. Correct3.Assist with a lumbar puncture. Correct4.Administer the prescribed antibiotics. Correct5.Monitor for signs of increased intracranial pressure (ICP). Bacterial meningitis is transmitted through respiratory droplets. The nurse would first ensure that all who come in contact with the child are appropriately gowned, gloved, and masked. An intravenous access device provides an avenue to administer prescribed fluids and medications; also, it provides a circulatory access in case of an emergency. The next priority is to obtain a sample of cerebrospinal fluid (CSF). This will help determine whether the cause is viral or bacterial, which will guide pharmacologic treatment by the health care provider. An antibiotic is usually not administered until the lumbar puncture is completed and CSF specimen is sent for culture. Complications, such as increased intracranial pressure and seizures, should be monitored for after the infant is admitted, placed on isolation, and antibiotics are started.

The nurse is caring for a toddler in acute respiratory distress precipitated by laryngotracheobronchitis. The child has a temperature of 103°F (39.4°C). Which is the priority nursing intervention? 1 Delivering humidified oxygen 2 Initiating measures to reduce fever 3 Monitoring respiratory status continuously 4 Providing support to diminish apprehension

The nurse is caring for a toddler in acute respiratory distress precipitated by laryngotracheobronchitis. The child has a temperature of 103°F (39.4°C). Which is the priority nursing intervention? 1 Delivering humidified oxygen 2 Initiating measures to reduce fever Correct3 Monitoring respiratory status continuously 4 Providing support to diminish apprehension Laryngeal spasms can occur abruptly; patency of the airway is determined through continuous monitoring for signs of respiratory distress. Providing oxygen is important, but maintenance of respiration is the priority. The fever should be treated, but it is not critical at 103°F (39.4°C); maintenance of respiration is the priority. Offering support is important, but maintenance of respiration is the priority.

The nurse is providing care to a client. Which nursing action has the highest priority when the nurse is moving a client with a neck and spinal cord injury during the assessment process? 1 Removing the cervical spine collar 2 Monitoring for autonomic dysreflexia 3 Implementing the logrolling technique 4 Administering the prescribed pain medication

The nurse is providing care to a client. Which nursing action has the highest priority when the nurse is moving a client with a neck and spinal cord injury during the assessment process? 1 Removing the cervical spine collar 2 Monitoring for autonomic dysreflexia Correct3 Implementing the logrolling technique 4 Administering the prescribed pain medication The priority when moving a client who presents with a neck and a spinal cord injury is to logroll the client whenever a transfer must occur. The nurse would not remove the cervical spine collar because this can exacerbate the original injury. The nurse would not monitor for autonomic dysreflexia during the acute phase of the injury. While monitoring and addressing pain is important, this is not the priority when transferring this client.

The registered nurse (RN) is caring for a client according to the total client care model. Which activity performed by the nurse manager would be appropriate in this situation? Select all that apply. One, some, or all responses may be correct. 1 Providing care to group of clients 2 Providing care to clients in ambulatory clinics 3 Delegating tasks to a licensed practical nurse (LPN) 4 Weighing the expense of an RN versus an LPN 5 Deciding the type of care provided by nursing assistive personnel

The registered nurse (RN) is caring for a client according to the total client care model. Which activity performed by the nurse manager would be appropriate in this situation? Select all that apply. One, some, or all responses may be correct. 1 Providing care to group of clients 2 Providing care to clients in ambulatory clinics 3 Delegating tasks to a licensed practical nurse (LPN) Correct4 Weighing the expense of an RN versus an LPN Correct5 Deciding the type of care provided by nursing assistive personnel Weighing the expense of RNs versus LPNs and unlicensed assistive personnel (UAP) is performed by the nurse manager in the total client care model of nursing. Providing care to the group of clients is the responsibility of a direct care nurse in the functional nursing model. Providing care to a client in an ambulatory clinic is the responsibility of the nurse manger in the functional nursing model. Delegating a task to an LPN is not the responsibility of the nurse manager; it is the responsibility of the RN.Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

The registered nurse (RN) is teaching the student nurse about various sites for assessing body temperature. Which statement(s) made by the student nurse is/are correct? Select all that apply. One, some, or all responses may be correct. 1 "The axilla is recommended to measure body temperature in unconscious clients." 2 "The oral cavity is suitable for clients with epilepsy to measure body temperature." 3 "The tympanic membrane is a preferred site of measuring body temperature in infants." 4 "The rectum is a preferred site of measuring body temperature in clients who underwent rectal surgeries." 5 "The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature."

The registered nurse (RN) is teaching the student nurse about various sites for assessing body temperature. Which statement(s) made by the student nurse is/are correct? Select all that apply. One, some, or all responses may be correct. Correct1 "The axilla is recommended to measure body temperature in unconscious clients." 2 "The oral cavity is suitable for clients with epilepsy to measure body temperature." Correct3 "The tympanic membrane is a preferred site of measuring body temperature in infants." 4 "The rectum is a preferred site of measuring body temperature in clients who underwent rectal surgeries." Correct5 "The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature." The axilla is the preferred site for measuring body temperature in unconscious clients. The tympanic membrane is the preferred site for measuring body temperature in newborns to reduce infant handling and heat loss. The region of the temporal artery reflects rapid changes in core temperature. The oral cavity is not a preferred site to measure body temperature for a client with epilepsy, oral surgery, trauma, or shaking chills. In clients with diarrhea, rectal abnormalities, bleeding tendencies, and clients who underwent rectal surgeries, the rectum is not the preferred site for measuring body temperature.

The registered nurse is instructing a nursing student to search for evidence in the scientific literature regarding the use of peppermint gum after abdominal surgery to reduce nausea and vomiting. The nursing student used the PICOT format to create questions to be used when conducting the research. Which question helps in the comparison of interest? 1 What problem is the client experiencing? 2 How much time is required to show the effectiveness of peppermint gum? 3 What is the result of using peppermint gum in clients who underwent abdominal surgery? 4 What is the current standard intervention for reducing nausea in clients after abdominal surgery?

The registered nurse is instructing a nursing student to search for evidence in the scientific literature regarding the use of peppermint gum after abdominal surgery to reduce nausea and vomiting. The nursing student used the PICOT format to create questions to be used when conducting the research. Which question helps in the comparison of interest? 1 What problem is the client experiencing? 2 How much time is required to show the effectiveness of peppermint gum? 3 What is the result of using peppermint gum in clients who underwent abdominal surgery? Correct4 What is the current standard intervention for reducing nausea in clients after abdominal surgery? In the PICOT format, the question "What is the current standard intervention for reducing nausea in clients after abdominal surgery?" helps in the comparison of interest because the query gives a better idea of which intervention is worthwhile to use in practice. To identify a client's population of interest, the question "What problem is the client experiencing?" is important. The question "How much time is required to show the effectiveness of peppermint gum?" is useful in identifying the amount of time required for the intervention to achieve an outcome. The question "What is the result of using peppermint gum in clients who underwent abdominal surgery?" helps identify the outcome of the intervention of interest.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

What is the sequence of events that occurs in the child's respiratory response to acidosis? Place the physiologic responses in the order in which they occur. 1. Hyperventilation 2. Increased CO2 elimination 3. Decreased blood H+ ions 4. Increased pH

What is the sequence of events that occurs in the child's respiratory response to acidosis? Place the physiologic responses in the order in which they occur. 1. Hyperventilation 2. Increased CO2 elimination 3. Decreased blood H+ ions 4. Increased pH

When a client and the family are informed about electroconvulsive therapy (ECT) as a treatment option, the family urges the client to agree. Which ethical principle is involved in this decision-making? 1 Justice 2 Veracity 3 Autonomy 4 Beneficence

When a client and the family are informed about electroconvulsive therapy (ECT) as a treatment option, the family urges the client to agree. Which ethical principle is involved in this decision-making? 1 Justice 2 Veracity Correct3 Autonomy 4 Beneficence Autonomy is the ethical principle of respecting the individual's independence and right to self-determination. In this situation the nurse focuses on helping the client make a choice. Justice is the ethical principle that requires all people to be treated fairly, regardless of sex, age, religion, diagnosis, marital status, or socioeconomic level. Veracity is the ethical principle that requires truthfulness. Beneficence is the duty to do good and promote the welfare of others.

When the chest x-ray for a client who has arrived at the emergency department with chest trauma shows multiple fractured ribs, which action will the nurse take next? 1 Administer the prescribed morphine sulfate. 2 Assist the client to take deep breaths and cough. 3 Check for paradoxical movement of the chest wall. 4 Teach the client about ways to manage rib pain.

When the chest x-ray for a client who has arrived at the emergency department with chest trauma shows multiple fractured ribs, which action will the nurse take next? 1 Administer the prescribed morphine sulfate. 2 Assist the client to take deep breaths and cough. Correct3 Check for paradoxical movement of the chest wall. 4 Teach the client about ways to manage rib pain. Flail chest can occur when multiple ribs are fractured and can compromise breathing efforts because of paradoxical movement during inspiration and expiration. Flail chest may require intubation and mechanical ventilation. Analgesic medication administration will be needed, because rib fractures make breathing painful, but further assessment of the client's ventilatory effort is needed prior to giving narcotic pain medications. The client with fractured ribs will need to deep breathe and cough to prevent atelectasis and pneumonia, but assessing for possible flail chest would be done first. Education about management of pain is needed, but this would be done after assessing for possible respiratory distress caused by flail chest.STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

Which behaviors indicate that a care provider is functioning as a primary nurse? Select all that apply. One, some, or all responses may be correct. 1 Provides most direct care for this client 2 Completes the client's plan of care 3 Coordinates care needs with ancillary staff 4 Examines and adjusts the care area budget 5 Discusses approaches to improve care responses

Which behaviors indicate that a care provider is functioning as a primary nurse? Select all that apply. One, some, or all responses may be correct. 1 Provides most direct care for this client Correct2 Completes the client's plan of care Correct3 Coordinates care needs with ancillary staff 4 Examines and adjusts the care area budget Correct5 Discusses approaches to improve care responses Actions of a primary nurse include completing the plan of care, coordinating care needs with ancillary staff, and discussing approaches with other care professionals to improve the client's outcomes of care. A primary nurse is not able to provide direct care 24/7; associate nurses will provide the direct care according to plan when the primary nurse is not on duty. Working with the care area budget is an activity of the nurse manager.Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which client in the emergency department would the nurse assess first? 1 Client with chest pressure and ST segment elevation on the electrocardiogram 2 Client who reports a sharp chest pain with deep inspiration for the past week 3 Client who has history of heart failure with ascites and bilateral 4+ ankle swelling 4 Client with palpitations and paroxysmal atrial fibrillation at a rate of 136 beats/minute

Which client in the emergency department would the nurse assess first? Correct1 Client with chest pressure and ST segment elevation on the electrocardiogram 2 Client who reports a sharp chest pain with deep inspiration for the past week 3 Client who has history of heart failure with ascites and bilateral 4+ ankle swelling 4 Client with palpitations and paroxysmal atrial fibrillation at a rate of 136 beats/minute The client with chest pressure and ST segment elevation on the electrocardiogram will need emergency treatment for ST segment elevation myocardial infarction (STEMI), including transport to the cardiac catheterization laboratory for percutaneous coronary intervention within 90 minutes, and should be seen first. The client with sharp pain with deep inspiration has symptoms consistent with pericarditis or pleural effusion and does need rapid assessment and treatment, but is not at risk for life-threatening complications. The client with heart failure and ascites and ankle swelling has symptoms of right ventricular failure that are not life-threatening. The client with palpitations and rapid atrial fibrillation will need assessment and evaluation, but the client experiencing myocardial infarction has a more life-threatening diagnosis.Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.

Which describes the primary purpose of evidence-informed nursing practice (EIP)? 1 Adhering to procedural guidelines 2 Providing safe nursing care regardless of the cost 3 Assessing clients systematically before implementing care 4 Using results from research to improve the outcome of nursing care

Which describes the primary purpose of evidence-informed nursing practice (EIP)? 1 Adhering to procedural guidelines 2 Providing safe nursing care regardless of the cost 3 Assessing clients systematically before implementing care Correct4 Using results from research to improve the outcome of nursing care In EIP nurses must search continually for scientific evidence to validate care that is provided to clients. Adhering to procedural guidelines does not relate specifically to EIP; however, it is inherent in all nursing care. Procedural guidelines would be evidence based. EIP is the result of an increasing demand for high-quality, cost-effective care. Assessing clients systematically before implementing care does not relate specifically to EIP; however, it is part of all nursing care.

Which concerns about the failure of resource capabilities leading to a crisis of the entire health care system are plausible during an epidemic such as the 2009-2010 swine flu? Select all that apply. One, some, or all responses may be correct. 1 Vast population seeking medical care 2 Illness and absenteeism of the workers 3 Public information campaigns about swine flu 4 Widespread vaccination programs of swine flu 5 Personal choice of the workers to be quarantined

Which concerns about the failure of resource capabilities leading to a crisis of the entire health care system are plausible during an epidemic such as the 2009-2010 swine flu? Select all that apply. One, some, or all responses may be correct. Correct1 Vast population seeking medical care Correct2 Illness and absenteeism of the workers 3 Public information campaigns about swine flu 4 Widespread vaccination programs of swine flu Correct5 Personal choice of the workers to be quarantined Pandemic infections may lead a large number of populations seeking medical care at once to create a resource crisis or failure of resource capabilities. Pandemic infections may affect the facility staff and cause staff shortages due to illness. Some staff may choose to be quarantined from the population to avoid the risk of further spreading infections. Public information campaigns help in managing the resources by educating people who seek evaluation, preventive treatment, or reassurance from a health care provider. Widespread vaccination programs help in managing the pandemic infection by preventing the spread of illness.

Which foods are excellent sources of vitamin E and betacarotene? 1 Spinach and mangoes 2 Fish and peanut butter 3 Oranges and grapefruit 4 Carrots and sweet potatoes

Which foods are excellent sources of vitamin E and betacarotene? Correct1 Spinach and mangoes 2 Fish and peanut butter 3 Oranges and grapefruit 4 Carrots and sweet potatoes The antioxidants vitamin E and betacarotene, which help inhibit oxidation and therefore tissue breakdown, are found in spinach and mangoes. Fish and peanut butter are excellent sources of vitamin E, not betacarotene. Oranges and grapefruits are excellent sources of vitamin C, not vitamin E and betacarotene. Carrots and sweet potatoes are excellent sources of betacarotene, not vitamin E.

Which information would the nurse provide about respite care services? Select all that apply. One, some, or all responses may be correct. 1 "Services are offered at home, in a day care setting, or in a health care institution that provides overnight care." 2 "They include services such as laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping." 3 "A group of residents live together, but each resident has his or her own room and shares dining and social activity areas." 4 "Medicare health care plans do not cover this service, and Medicaid has strict requirements for services and eligibility." 5 "It is a service that provides short-term relief or 'time off' for people, providing home care to an ill, disabled, or frail older adult."

Which information would the nurse provide about respite care services? Select all that apply. One, some, or all responses may be correct. Correct1 "Services are offered at home, in a day care setting, or in a health care institution that provides overnight care." 2 "They include services such as laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping." 3 "A group of residents live together, but each resident has his or her own room and shares dining and social activity areas." Correct4 "Medicare health care plans do not cover this service, and Medicaid has strict requirements for services and eligibility." Correct5 "It is a service that provides short-term relief or 'time off' for people, providing home care to an ill, disabled, or frail older adult." Respite care service is offered at home, in day care settings, or in a health care institution that provides overnight care. Currently, Medicare does not cover respite care service, and Medicaid has strict requirements for services and eligibility. Respite care services provide short-term relief or "time off" for people, providing home care to an ill, disabled, or frail older adult. Assisted living includes services such as laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping. In assisted living, a group of residents live together, but each resident has his or her own room and shares dining and social activity areas.

Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct. 1 Avoid eating from buffets. 2 Obtain annual flu vaccinations. 3 Perform regular hand hygiene. 4 Stay away from crowded areas. 5 Report a temperature greater than 100.5°F.

Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct. Correct1 Avoid eating from buffets. Correct2 Obtain annual flu vaccinations. Correct3 Perform regular hand hygiene. Correct4 Stay away from crowded areas. Correct5 Report a temperature greater than 100.5°F. Clients who receive an organ transplant need to take immunosuppressant medications for the rest of their lives to prevent organ rejection. These medications put the client at increased risk for infection. The nurse would provide infection prevention teaching to the client after renal transplant, which would include instructions to avoid eating from buffets, get an annual flu vaccine, practice regular hand hygiene, and avoid crowded areas. Clients would also be instructed to report a temperature greater than 100.5°F to their health care provider as it could indicate infection or organ rejection and requires treatment.

Which intervention has the highest priority for the nurse providing prehospital care for a client who experiences symptoms of acute mountain sickness while climbing a mountain? 1 Administering acetazolamide 2 Administering dexamethasone 3 Providing oxygen (O2) mask to the client 4 Having the client descend to lower altitude

Which intervention has the highest priority for the nurse providing prehospital care for a client who experiences symptoms of acute mountain sickness while climbing a mountain? 1 Administering acetazolamide 2 Administering dexamethasone 3 Providing oxygen (O2) mask to the client Correct4 Having the client descend to lower altitude The most important intervention to manage serious altitude-related illnesses is facilitating descent of the client to a lower altitude. Acetazolamide helps a client acclimatize to higher altitudes and is administered before climbing. While descending, the client is administered dexamethasone and provided with an O2 mask.

Which is the similarity between the stage-crisis theory given by Havighurst and the psychosocial development theory given by Erikson? 1 Based on developmental tasks 2 Incorporate eight stages of development 3 Based on changes in a person's thoughts and emotions 4 Emphasize that a child's growth is directed by individual gene activity

Which is the similarity between the stage-crisis theory given by Havighurst and the psychosocial development theory given by Erikson? Correct1 Based on developmental tasks 2 Incorporate eight stages of development 3 Based on changes in a person's thoughts and emotions 4 Emphasize that a child's growth is directed by individual gene activity Both stage-crisis theory and psychosocial development theory are based on developmental tasks. Similar to Erikson's theory, Havighurst's theory demonstrates that the successful resolution of a developmental task is essential for successful progression through life. Stage-crisis theory has six stages; psychosocial development theory has eight stages of development. Gesell's theory of development shows that a child's development is directed by gene activity. The moral development theory emphasizes the changes in a person's thoughts, emotions, and behaviors that influence beliefs about what is right or wrong.Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. One, some, or all responses may be correct. 1 Inserting a nasogastric tube 2 Immobilizing the cervical spine 3 Arranging for diagnostic studies 4 Preparing for chest tube insertion 5 Applying direct pressure to a wound

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. One, some, or all responses may be correct. 1 Inserting a nasogastric tube Correct2 Immobilizing the cervical spine 3 Arranging for diagnostic studies Correct4 Preparing for chest tube insertion Correct5 Applying direct pressure to a wound

Which nursing care intervention is the priority for the client status-post mastectomy and breast augmentation receiving anthracycline chemotherapy? 1 Reminding the client to expect soreness in the chest 2 Teaching the client to avoid blood pressure measurements on the affected side 3 Teaching the client that she or he may face difficulty in raising the arm 4 Instructing the client to report a chronic cough and shortness of breath

Which nursing care intervention is the priority for the client status-post mastectomy and breast augmentation receiving anthracycline chemotherapy? 1 Reminding the client to expect soreness in the chest 2 Teaching the client to avoid blood pressure measurements on the affected side 3 Teaching the client that she or he may face difficulty in raising the arm Correct4 Instructing the client to report a chronic cough and shortness of breath Anthracyclines can cause cardiotoxic side effects. A client who is undergoing chemotherapy with anthracyclines is instructed to report a chronic cough and shortness of breath. After breast augmentation, a client is taught that she should expect soreness in the chest. After a mastectomy, a client is taught to avoid blood pressure measurements in the affected limb. After mastectomy and breast augmentation, a client is taught that she may have difficulty in raising the arm.

Which organization provides scope and practice guidelines on the roles and responsibilities for nursing and nursing specialties? Select all that apply. One, some, or all responses may be correct. 1 State Nursing Association 2 National League of Nursing 3 American Nurses Association 4 Academy of Medical Surgical Nurses 5 Quality and Safety Education for Nurses

Which organization provides scope and practice guidelines on the roles and responsibilities for nursing and nursing specialties? Select all that apply. One, some, or all responses may be correct. 1 State Nursing Association 2 National League of Nursing Correct3 American Nurses Association 4 Academy of Medical Surgical Nurses 5 Quality and Safety Education for Nurses The American Nurses Association develops and publishes scope and standards of practice guidelines for nursing and nursing specialties. Many professional organizations have state-level nursing associations, but they do not publish standards and scope of practice. The National League of Nursing is a professional organization related to the education of nurses. The Academy of Medical Surgical Nurses publishes scope and standards of practice for general medical surgical nursing, but not nursing and nursing specialties. Quality and Safety Education for Nurses supports development of the knowledge, skills, and attitudes needed to improve the quality and safety of the health care system.

Which questions would the nurse consider to assess and ensure delegation to the right person? Select all that apply. One, some, or all answers may be correct. 1 Is the prospective delegatee a willing and able employee? 2 Does the delegatee understand the directions and expected results of the task? 3 Does the delegatee understand how, what, and when to report to the delegator? 4 Is it clear that the delegatee will provide feedback related to the task when appropriate? 5 Does the delegatee have the knowledge and experience to perform the specific task safely?

Which questions would the nurse consider to assess and ensure delegation to the right person? Select all that apply. One, some, or all answers may be correct. Correct1 Is the prospective delegatee a willing and able employee? 2 Does the delegatee understand the directions and expected results of the task? 3 Does the delegatee understand how, what, and when to report to the delegator? 4 Is it clear that the delegatee will provide feedback related to the task when appropriate? Correct5 Does the delegatee have the knowledge and experience to perform the specific task safely? The right delegatee is chosen on the basis of the person's willingness and ability. The nurse would assess the knowledge and experience of the prospective delegatee to perform the specific task safely and fulfill the expected outcomes. The right direction and documentation are assessed by the delegatee's ability to understand the directions and expected results of the task. It can also be assessed on the basis of the delegatee's understanding of how, what, and when to report to the delegator. The right supervision is providing feedback to the delegatee, related to the task, when appropriate.

Which roommate would the nurse manager assign to a 4-year-old boy who has been admitted to the pediatric unit with nephrotic syndrome? 1 3-year-old boy with impetigo 2 2-year-old boy with pneumonia 3 5-year-old girl with thalassemia 4 4-year-old girl with conjunctivitis

Which roommate would the nurse manager assign to a 4-year-old boy who has been admitted to the pediatric unit with nephrotic syndrome? 1 3-year-old boy with impetigo 2 2-year-old boy with pneumonia Correct3 5-year-old girl with thalassemia 4 4-year-old girl with conjunctivitis A child with nephrotic syndrome is at risk for infection. The child with thalassemia is noninfectious and therefore an appropriate roommate. In addition, the closeness of their ages will encourage preschool socialization. Impetigo, pneumonia, and conjunctivitis are all caused by pathogens; exposure of the child with nephrotic syndrome to infection should be avoided.

Which statements would the nurse include in teaching about the Hospital Incident Command Systems (HICS)? Select all that apply. One, some, or all responses may be correct. 1 It is a part of the National Disaster Medical System. 2 Specific job action sheets are distributed to all HICS personnel. 3 The emergency operations center or command center is established by HICS personnel. 4 All internal requests and communication with field teams should be coordinated through the emergency operations center. 5 A public information officer manages logistics, planning, finance, and operations as appropriate to the type and scale of the event.

Which statements would the nurse include in teaching about the Hospital Incident Command Systems (HICS)? Select all that apply. One, some, or all responses may be correct. 1 It is a part of the National Disaster Medical System. Correct2 Specific job action sheets are distributed to all HICS personnel. Correct3 The emergency operations center or command center is established by HICS personnel. Correct4 All internal requests and communication with field teams should be coordinated through the emergency operations center. 5 A public information officer manages logistics, planning, finance, and operations as appropriate to the type and scale of the event. Specific job action sheets that predefine reporting relationships and list prioritized tasks and responsibilities are distributed to all HICS personnel. An emergency operations center or command center with accessible communication technology is established by HICS personnel to manage the overall incident. All internal requests related to additional personnel and resources, as well as communication with field teams, should be coordinated through the emergency operations center to maintain unity of command. HISC is a part of the National Incident Management System. The Disaster Medical Assistance Team (DMAT) is a part of the National Disaster Medical System. A chief is appointed to manage logistics, planning, finance, and operations as appropriate to the type and scale of the event. A public information officer serves as a liaison between the health care facility and the media.

Which temperament would an easy child display? Select all that apply. One, some, or all responses may be correct. 1 Is open and adaptable to change 2 Requires a more structured environment 3 Is regular and predictable in his or her habits 4 Displays a mild to moderately intense mood that is typically positive 5 Displays a mild but passive resistance to novelty or changes in routine

Which temperament would an easy child display? Select all that apply. One, some, or all responses may be correct. Correct1 Is open and adaptable to change 2 Requires a more structured environment Correct3 Is regular and predictable in his or her habits Correct4 Displays a mild to moderately intense mood that is typically positive 5 Displays a mild but passive resistance to novelty or changes in routine An easy child is open and adaptable to change, is regular and predictable in his or her habits, and displays a mild to moderately intense mood that is typically positive. A difficult child requires a more structured environment. A slow-to-warm up child responds with mild but passive resistance to novelty or changes in routine.