EXAM 1 study questions

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A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action would the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client? a. Desipramine b. Duloxetine c. Morphine sulfate d. Nortriptyline

The assistive personnel (AP) reports to the registered nurse that a postoperative client has a pulse of 132 beats/min and a blood pressure of 168/90 mm Hg. What response by the nurse is most appropriate? a. Ask the AP to repeat the client's vital signs in 15 minutes. b. Assess the client for pain. c. Ask the client if something is bothersome. d. Instruct the AP to reposition the client.

A, B, C, D, E. F All of these choices are attributes of client-centered care. Respect for all individuals is especially important.

The nurse provides client-centered care for an older client who was admitted from an assisted living facility. What attributes would the nurse demonstrate when providing care for this client? (Select all that apply.) A. Physical comfort B. Emotional support C. Client respect D. Communication and education E. Care coordination F. Transition and continuity of care

Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent. b. Gives the client accurate information when questioned. c. Keeps the promises made to the client and family. d. Treats the client fairly compared to other clients.

C Systems thinking can exist globally, nationally, or locally. An example of global level systems thinking is the determinants of health as these are elements of health that are developed on a global level in relation to population health.

Which nursing element reflects systems thinking at the global level of practice? A. Facility health policy B. Quality improvement initiative C. Determinants of health D. Interprofessional practice

Which nursing statement reflects an awareness of systems thinking? A."My client values spirituality when receiving care." B."I looked at our unit policy to be sure it was evidence-based." C."The care we provide to prevent pressure injuries should work on other units." D. "Appropriate documentation enhances continuity of care."

C, D, E Handwashing is the number-one way to prevent infection in clients. Checklists can help prevent mistakes in care for a surgical client, thus ensuring a safe environment. Adhering to the five rights of medication administration helps to prevent errors in this important nursing care activity, providing for increased safety in client care. Although restraints may help clients who are confused to keep from hurting themselves, they are potentially risky and are used infrequently because of the harm they can cause. Respect is an important element in client care, but it is not directly tied to the provision of a safe care setting.

Which principal nursing actions best support a focus on client safety? (Select all that apply.) A. Respect for others B. Client restraints C. Preoperative checklists D. Handwashing E. Five rights of drug administration

C Normal serum sodium ranges between 136 and 145 mEq/L (mmol/L). Hypernatremia is a serum sodium value greater than 145 mEq/L (mmol/L). In option A, the serum potassium is normal. In options C, the serum potassium value is above normal and indicates hyperkalemia. In option B, the serum sodium value is low, reflecting hyponatremia.

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? A. Sodium 132 mEq/L (mmol/L) B. Potassium 3.5 mEq/L (mmol/L) C. Sodium 148 mEq/L (mmol/L) D. Potassium 5.3 mEq/L (mmol/L)

1. Which of the following factors does the nurse recognize as being a risk for altered sensory perception in the older adult client? A. Diabetes mellitus B. Hypotension C. Osteoarthritis D. Peptic ulcer disease

A new nurse asks the precepting nurse "What is the best way to assess a client's pain?" Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Client's self-report d. Objective observation

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

A nurse on the medical-surgical unit has received a hand-off report. Which client would the nurse see first? a. Client being discharged later on a complicated analgesia regimen. b. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale. c. Postoperative client who received oral opioid analgesia 45 minutes ago. d. Client who has returned from physical therapy and is resting in the recliner.

D The nurse will administer acetaminophen as prescribed. Nonopioid analgesics such as acetaminophen are the first line of therapy for mild to moderate pain.Hydromorphone is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Midazolam is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Oxycodone is an opioid and is not needed for a mild headache.

A postoperative client reports, "I have pain from a mild headache." Which PRN medication will the nurse administer? A. Oxycodone B. Hydromorphone C. Midazolam D. Acetaminophen

After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates that the client needs additional teaching? a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."

C The largest application of health care informatics is the growing trend of the use of electronic medical records (EMRs) for documenting interprofessional care. Computers may be located at the client's bedside or in a central area for ease of access for documentation. Computers allow quick communication among health care professionals to enhance collaboration and coordination of care; however, this type of communication typically would not take place at the client's bedside. Bedside computers in the health care setting are not intended for client use. The Internet provides ways to search multiple sources of information and retrieve data efficiently; however, this would not be done at the client's bedside.

Bedside (point-of-care) computers are an example of informatics used in health care primarily for which purpose? A. Enhancing collaboration and coordination of care B. Offering clients access to email and the Internet C. Documenting interprofessional care D. Retrieving data for evidence-based practice

D A client with multiple rib fractures may have poor gas exchange from shallow breathing because of pain and because the rib fractures may inhibit adequate chest expansion. A client who is anxious and breathing rapidly is at risk for respiratory alkalosis, not acidosis. A normal saline bolus does not result in respiratory acidosis. An increased urinary output would not be a stimulus for a respiratory acid-base imbalance.

For which client does the nurse remain alert for the possibility of respiratory acidosis? A. Client with increased urinary output B. Client who is anxious and breathing rapidly C. Client receiving IV normal saline bolus D. Client with multiple rib fractures

How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

A, C, D While taking a potassium-sparing diuretic, the client is at risk for developing hyperkalemia and needs to avoid foods and other substances that contain higher concentrations of potassium. These include salt substitutes, meat and fish, and citrus fruit. Foods lowest in potassium include eggs, bread, and cereal grains, as well as most berries.

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) A. Red meat B. Cereal C. Citrus fruit D. Salt substitutes E. Eggs F. Bread

In reviewing the electrolytes of a client the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth

Into which environment of care would the nurse anticipate sending a client who is experiencing complications from COVID-19? A. Medical home B. Community health care C. Inpatient care D. Rehabilitation care

B, C, D, E

Nurses at a conference learn the process by which pain is perceived by the client. Which processes are included in the discussion? (Select all that apply.) a. Induction b. Modulation c. Sensory perception d. Transduction e. Transmission f. Transition

Once the nurse has considered all possible collaborative and client problems, what action does the nurse take next? a. Act on the observed cues. b. Determine desired outcomes. c. Generate solutions. d. Prioritize the hypotheses.

C The charge nurse will need to provide further education to the new nurse regarding the statement, "Older adults typically believe that expressing pain is acceptable."Older adults typically do not believe that expressing pain is acceptable. Many older adults believe that pain is irrelevant and is "just part of getting older."As a result, many older adults are at great risk for undertreated pain. In addition, some health care providers have outdated beliefs about older adults' pain sensitivity, tolerance, and ability to take opioids.

The charge nurse is working with a new nurse. Which statement by the new nurse requires additional teaching by the charge nurse? A. "Older adults usually believe that pain is irrelevant and is to be expected." B. "Older adults are at a very high risk for undertreated pain." C. "Older adults typically believe that expressing pain is acceptable." D. "I always assess older adults for present pain."

A, B, C, E

The expert nurse understands that critical thinking requires which elements to be present? (Select all that apply.) a. Based on logic, creativity, and intuition b. Driven by needs c. Focused on safety and quality d. Grounded in a specific theory e. Guided by standards f. Requires forming options about evidence

A The client admitted for excessive salicylate (acid) would likely have an acid-base imbalance caused by salicylate intoxication. A client admitted with chronic pancreatitis is not likely to develop an acid-base imbalance so ABGs would not be indicated. The client with a history of controlled type 2 diabetes would likely not have an acid-base imbalance. Although clients with COPD are at increased risk of respiratory acidosis, a newly diagnosed client would not have an acid-base imbalance but may have a slightly decreased PaO2.

The nurse receives the shift report. Which client would the nurse anticipate a need for arterial blood gas assessment? A. Admitted for excessive salicylate ingestion B. Admitted with chronic pancreatitis C. Recent diagnosis of mild chronic obstructive lung disease D. History of controlled type 2 diabetes

Which documentation will the nurse record for a client who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? A. Reports acute pain at the surgical site. B. Persistent pain reported around the surgical site. C. Experiences neuropathic pain near the surgical site. D. Discomfort has progressed to chronification of pain.

A A positive Chvostek sign is associated with alkalosis accompanied by a low serum calcium level. The hypocalcemia cause overexcitement of the nervous system with dizziness, agitation, confusion, and hyperreflexia, which may progress to seizures. Tingling or numbness may occur around the mouth and in the toes. If the client has hypocalcemia, the nurse must report the finding immediately to the health care provider so actions can be taken to prevent harm.

Which laboratory value will the nurse check immediately to prevent harm for a client with metabolic alkalosis who now has a positive Chvostek sign? A. Serum calcium B. Serum magnesium C. Serum glucose level D. Serum sodium

E Unlike metabolic acidosis, respiratory acidosis results from only one cause—retention of CO2, causing overproduction of free hydrogen ions. Bicarbonate is not involved as a cause or as a compensatory mechanism. Recall that carbon dioxide and hydrogen ions are directly related in human physiology. An increase in one always causes an increase in the other. Retention of CO2 is the problem, not failure of the body to directly eliminate hydrogen ions.

Which mechanism will the nurse consider the most likely cause of pure acute respiratory acidosis in a client who has bilateral pneumonia? A. Underelimination of bicarbonate ions B. Underproduction of hydrogen ions C. Overelimination of bicarbonate ions D. Overelimination of hydrogen ions E. Overproduction of hydrogen ions F. Underelimination of hydrogen ions H. Underproduction of bicarbonate ions I. Overproduction of bicarbonate ions

. The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.

A, B, D, F

1. The nurse is assessing an older adult and notes that the client is at risk for constipation. Which statements will the nurse include in health teaching for this client to promote optimum bowel elimination? Select all that apply. A. "Be sure to include plenty of fresh fruits and vegetables in your diet each day." B. "Eat lots of high fiber foods, including whole grains each day." C. "Be sure to take a laxative every day to clean out your bowels and prevent toxins." D. "Exercise several times a week to keep our bowels working for regular elimination." E. "Drink at least 3 caffeinated beverages every day to keep your bowels stimulated." F. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom."

C In the healthy adult, a maximum daily dose below 4000 mg is rarely associated with liver toxicity. Many experts recommend reducing the daily dose (e.g., 2500 to 3000 mg daily) when used for long-term treatment in older adults. Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice for many people in pain, especially older adults. The dose is appropriate; more is not indicated or advised.Acetaminophen is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding.

A 44-year-old client with osteoarthritis pain tells the nurse, "I take two extra-strength acetaminophen (500 mg) every 8 hours." How does the nurse respond? A. "More acetaminophen is needed to provide effective pain relief for you." B. "You will need to have routine blood draws to monitor clotting time." C. "That is the appropriate dose of acetaminophen for your pain." D. "Aspirin would be a better, more effective choice for your pain relief."

C Complementary and integrative therapies are most often used to supplement, not replace, medication management. The nurse needs to obtain more data, and will ask for more information about the client's plan. Contacting the health care provider to cancel the medication order is not appropriate. Telling the client that his idea is wonderful and will definitely work is not appropriate, as alternative strategies alone, may not work to relieve the client's pain. Telling the client that his or her plan will not work is dismissive of the client. In addition, the client may not need to be prescribed opioids for the pain.

A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." Which nursing response is appropriate? A. "I will discuss cancelling your medication order with your health care provider." B. "That sounds like a wonderful idea; and I think it will definitely work!" C. "That sounds like a great plan; can you tell me more about it?" D. "Your plan will not work; people with your type of pain need opioids."

A client had a recent thromboembolism and must resume work which requires frequent car and plane travel. What self-care measure does the nurse teach to reduce the risk of impaired clotting in this client? a. Get up and walk around at least every 2 hours while traveling. b. Use a soft toothbrush and an electric razor for safety. c. Be sure to sit with the legs elevated as much as possible. d. Increase fiber in the diet so as not to strain to move the bowels.

A client has been receiving the same dose of an intravenous opioid for two days to manage post-surgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? A. There is likely a history of addiction. B. Tolerance to the opioid is developing. C. Physical dependence is developing. D. The client is opioid-naïve.

A, B, C, D

A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the client about diet changes to improve wound healing. What diet selections does the nurse evaluate as good understanding by the client? (Select all that apply.) a. Chicken breast b. Orange juice c. Boost supplement d. Spinach salad e. Cantaloupe f. Whole wheat bread

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client's oxygen saturation is 87%. Which action would the nurse perform first? a. Apply oxygen at 4 L/min. b. Attempt to arouse the client. c. Give naloxone (Narcan). d. Notify the Rapid Response Team.

A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority nursing diagnosis have been met? a. Client reports satisfaction with undergarments for incontinence. b. Client reports drinking 8 to 9 glasses of water each day. c. Skin in perineal area is intact without redness on inspection. d. Family states that client is more active and socializes more.

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the provider's phone number by the telephone. c. Make sure that all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room.

A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client's health history would lead the nurse to consult with the primary health care provider over the choice of medication? a. 25-pack-year smoking history b. Drinking 3 to 5 beers a day c. Previous peptic ulcer d. Taking warfarin

A, D

A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. Which actions by the nurse are most appropriate? (Select all that apply.) a. Consult with the surgeon and voice objections. b. Delegate administration of the placebo to another nurse. c. Give the placebo and reassess the client's pain. d. Notify the nurse manager of the placebo prescription. e. Tell the client what medications were prescribed.

A client reports increasing diffuse pain in the entire right leg. What is the nurse's priority action at this time? A. Elevate the right leg on a pillow. B. Perform a peripheral vascular assessment. C. Check for swelling in the right leg. D. Notify the Rapid Response Team immediately.

A, E, F Interventions recommended for the client include distraction, music therapy, and premedication. Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment.Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain, but its use during a dressing change would not be feasible.

A client reports increasing pain during dressing changes to the nurse. Which interventions are recommended for the client? (Select all that apply.) A. Music therapy B. Assistance by the client with the dressing change C. Epidural analgesic D. Transcutaneous electrical nerve stimulation (TENS) E. Distraction F. Premedication

A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? A. "This is common side effect of gabapentin and will decrease with use." B. "Stop taking the medication and contact the healthcare provider." C. "The dizziness is caused by the neuropathic pain, not the medication." D. "The dizziness is likely from another medication, not the gabapentin."

A client tells the nurse, "I just don't feel like being sexually intimate with my partner any more." What is the appropriate nursing response? A."How often do you expect to have sex?" B."Do you not find your partner attractive?" C."Would you consider seeing a mental health professional?" D."Have you experienced pain or difficulty with intercourse?"

D The nursing intervention with the highest priority in the client's care plan is the use of preemptive analgesia. This technique is designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay.Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the client to perform activities of daily living is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day.

A client who had a hip replacement 2 days ago, reports having pain rated as a 7 on a pain scale of 0-10. What nursing intervention is the highest priority? A. Teaching key points of the relaxation response B. Incorporating activities of daily living as soon as possible C. Encouraging diversional activities D. Using preemptive analgesia

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the client's care plan? a. As-needed pain medication after therapy b. Pain medications prior to therapy only c. Patient-controlled analgesia with a basal rate d. Round-the-clock analgesia with PRN analgesics

A The nurse will request that the visitor allow the client to push the button for medication when needed. The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues.Telling the family member not to touch any equipment in the client's room is not only nonspecific, but it may also be perceived as disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the client is asleep does not mean that the client is pain-free.

A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What will the nurse say to the visitor? A. "Please allow the client to push the button when needed." B. "Please don't touch any equipment in the client's room." C. "Thank you. I am sure the client appreciated that." D. "The client is asleep and is not in pain."

B, D, E

A client with a broken arm had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate? (Select all that apply.) a. Ask for a physical therapy consult. b. Educate the client on cold therapy. c. Offer to provide a heating pad. d. Repeat the ice application. e. Teach the client relaxation techniques. f. Offer the client headphones with music.

A The nurse will administer the pain medication as requested. Both types of persistent (chronic) pain (chronic cancer pain and chronic noncancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's objective symptoms when managing chronic cancer pain.The nurse would not decrease pain medication under the assumption that, because the client does not exhibit signs of pain, the client must not have any pain. Unless the client is involved in a clinical research trial, giving a placebo in place of medication is never appropriate. It is never appropriate to withhold prescribed pain medication unless the client is medically unstable and the nurse would contact the health care provider.

A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical signs of pain. What will the nurse do next? A. Administer the pain medication as requested. B. Withhold the pain medication. C. Decrease the client's standard pain medication dose. D. Give the client a placebo and monitors the outcome.

C The nurse expects the client to have a physical dependence on the opioid. Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms.Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the client's situation. Tolerance is similar to physical dependence, but occurs earlier and consists of a decrease in one or more of the effects of the opioid. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the client's situation.

A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? A. Tolerance B. Pseudoaddiction C. Physical dependence D. Addiction

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm? A. Hold the next dose of the prescribed antidiarrheal drug B. Assess bowel sounds in all four abdominal quadrants C. Assess the client's response to the Chvostek test A. Increase the IV flow rate of the normal saline infusion

A diabetic client becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50, PaCO2 30, HCO3 : 24, and PaO2 68. What does the nurse recognize as the primary factor causing this the acid-base imbalance? a. Atelectasis due to respiratory muscle fatigue b. Hyperventilation due to poor oxygenation c. Hypoventilation due to morphine PCA d. Kussmaul respirations due to glucose of 102 mg/dL (5.7 mmol/L)

A hospitalized client has a history of depression for which sertraline is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? a. Hydrocodone and acetaminophen b. Hydromorphone c. Meperidine d. Tramadol

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse

B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are several national and international organizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client's safety. The other actions are important for quality nursing, but they are not as vital as providing safety. Not making medication errors does provide safety, but is too narrow in scope to be the best answer

A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care

A new nurse reports to the nurse preceptor that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best? a. "Being able to sleep doesn't mean pain doesn't exist." b. "Have you ever experienced any type of pain?" c. "The client should be assessed for drug addiction." d. "You're right; I would put the medication back."

A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best? a. "All staff nurses are required to participate in quality improvement here." b. "Even being new, you can implement activities designed to improve care." c. "It's easy to identify what indicators would be used to measure quality." d. "You should ask to be assigned to the research and quality committee."

A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don't make assumptions about his or her health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population.

A nurse asks the charge nurse to explain the difference between critical thinking and clinical judgment. What statement by the charge nurse is best? a. "Clinical judgment is often clouded by erroneous hypotheses." b. "Clinical judgment is the observable outcome of critical thinking." c. "Critical thinking requires synthesizing interactions within a situation." d. "Critical thinking is the highest level of nursing judgment."

A nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. Which response by the charge nurse is best? a. "A multimodal approach is the preferred method of control." b. "Clients are consumers and they demand lots of pain medicine." c. "We are all much more liberal with pain medications now." d. "Pain is so complex it takes different approaches to control it."

A, B, E, F

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances

A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L (16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse take next? a. Assess client's rate, rhythm, and depth of respiration. b. Measure the client's pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the primary health care provider.

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which assessment would the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes . c. Musculoskeletal strength d. Level of orientation

A, B, C

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L (18 mmol/L). For which clinical signs and symptoms would the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes . b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau sign f. Flaccid paralysis

B, E

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

A nurse assesses a client who is prescribed furosemide for hypertension. For which acid-base imbalance does the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

A, E

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance would the nurse assess? (Select all that apply.) a. Positive Chvostek sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability f. Tetany

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure.

A, D, E

A nurse assures a client experiencing abdominal surgical pain that comfort measures, including drug therapy, will be provided as the client needs them. Which ethical principles apply in the situation? Select all that apply. A. Beneficence B. Social justice C. Autonomy D. Fidelity E. Veracity

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

A, C, D, E, F

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client's hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.

A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema

B R stands for recommendation or request for a new modality or treatment to better manage the client's problem.

A nurse gives report about a client whose pain in uncontrolled and suggests that the client receive continuous analgesic administration rather than PRN analgesics. Which step of the SBAR hand-off report is the nurse using? A. S B. R C. B D. A

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance would the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek sign

A, E, F

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider.

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain.

B, C, E

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis—young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis—older adult who is following a carbohydrate-free diet c. Respiratory alkalosis—client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis—postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis—older client prescribed antacids for gastroesophageal reflux disease

A nurse is assessing pain in an older adult. Which action by the nurse is best? a. Ask only "yes-or-no" questions so the client doesn't get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale

A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? a. "I would like you to order a different pain medication." b. "This client has allergies to morphine and codeine." c. "Dr. Smith doesn't like nonsteroidal anti-inflammatory meds." d. "This client had a vaginal hysterectomy 2 days ago."

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin.

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L (22 mmol/L). What action would the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client's nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog . c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is breathing rapidly. What response by the charge nurse is best? a. Anxiety is causing the client to breathe rapidly. b. The client is trying to get rid of excess body acids. c. The rapid respirations cause buildup of bicarbonate. d. An increased respiratory rate is due to increased metabolism.

A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16 mmol/L). Which primary health care provider order does the nurse expect to receive? a. Furosemide 40 mg b. Sodium bicarbonate c. Mechanical ventilation d. Indwelling urinary catheter

A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is most important to ensure client safety? a. Assess and record vital signs every 4 hours. b. Instruct the client to report any unrelieved pain. c. Monitor for numbness and tingling in the legs. d. Perform frequent neurologic assessments.

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.

A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary health care provider. d. Repeat the blood pressure in 15 minutes.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.

A, B, C, F

A nurse is caring for clients on an inclient surgical unit. Which clients does the nurse identify as having a risk for impaired immunity? (Select all that apply.) a. 86 years old b. Has type 2 diabetes c. Taking prednisone d. Has many allergies e. Drinks a beer a day f. Low socioeconomic status

A, B, C, E, F

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses

B, C, D, E, F

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client would the nurse see first? a. Client who is crying and agitated b. Client with a heart rate of 104 beats/min c. Client with a Pasero Scale score of 4 d. Client with a verbal pain report of 9

A nurse is caring for four clients. Which client does the nurse assess first for impaired cognition? a. A 28-year-old client 2 days post-open cholecystectomy b. An 88-year-old client 3 days post-hemorrhagic stroke c. A 32-year-old client with a 20-pack-year history of smoking d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L)

B, C, D, F

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

A nurse is confused on why systems thinking is important since working on the unit involves caring for a few specific clients. What explanation by the nurse manager is best? a. "It's a good way to conduct root-cause analysis." b. "It is important for quality improvement and safety." c. "Systems thinking helps you see the bigger picture." d. "You may enter management 1 day and need to know this."

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

A, B, C, D, F

A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care. b. Coordinates discharge planning for home safety. c. Participates in comprehensive client rounding. d. Routinely asks other disciplines about client progress. e. Shows the nursing care plans to other disciplines. f. Delegate tasks to unlicensed personnel appropriately.

A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband.

A, B, E

A nurse is planning a community education event-related to impaired cellular regulation. What teaching topics would the nurse include in this event? (Select all that apply.) a. Ways to minimize exposure to sunlight b. Resources available for smoking cessation c. Strategies to remain hydrated during hot weather d. Use of indoor tanning beds instead of sunbathing e. Creative cooking techniques to increase dietary fiber f. How to determine sodium content in food?

A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L (26 mmol/L). Which question would the nurse ask when developing this client's plan of care? a. "Do you take any over-the-counter medications?" b. "You appear anxious. What is causing your distress?" c. "Do you have a history of anxiety attacks?" d. "You are breathing fast. Is this causing you to feel light-headed?

B, C, D

A nurse is planning care for a client who is lethargic and confused. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19 mmol/L). Which questions would the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. "Are you taking any antacid medications?" b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" d. "Have you been participating in strenuous activity?" e. "Are you experiencing any shortness of breath?"

A, B, D, F

A nurse is planning interventions that regulate acid-base balance to ensure that the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.) a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs f. Changes in GI tract excitability

A nurse is planning primary prevention measures for community-dwelling adults to prevent visual impairment. What action by the nurse will best meet this objective? a. Provide glaucoma screening. b. Assess visual acuity. c. Teach clients about instilling eyedrops. d. Offer a healthy lifestyle class.

A nurse is preparing to give a client ketorolac intravenously for pain. Which assessment findings would lead the nurse to consult with the primary health care provider? a. Bilateral lung crackles b. Hypoactive bowel sounds c. Self-reported pain of 3/10 d. Urine output of 20 mL/2 hr

A, C, D, E

A nurse is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.) a. Neuropathic pain sometimes accompanies amputation. b. Nociceptive pain originates from abnormal pain processing. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.

A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse-client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that has achieved Magnet status. d. Work in a facility affiliated with a medical or nursing school.

A, B, D, E, F

A nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.) a. Decreased immune response b. Development of chronic pain c. Increased gastrointestinal (GI) motility d. Possible immobility e. Slower healing f. Negative quality of life

A, D, E, F

A nurse learns the concepts of addiction, tolerance, and dependence. Which information is accurate? (Select all that apply.) a. Addiction is a chronic physiologic disease process. b. Physical dependence and addiction are the same thing. c. Pseudoaddiction can result in withdrawal symptoms. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease. f. Physical dependence occurs after repeated doses of an opioid.

A, B, C, E

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Create a template of suggested topics to include in report. c. Encourage staff to ask questions during hand-off. d. Give raises based on compliance with reporting. e. Provide education on the SBAR method of communication

A, B, D, E

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interprofessional team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care f. Formalizing systems thinking when implementing care

A nurse on the postoperative inpatient unit receives hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client would the nurse see first? a. Client who appears to be sleeping soundly. b. Client with no bolus request in 6 hours. c. Client who is pressing the button every 10 minutes. d. Client with a respiratory rate of 8 breaths/min.

A, C, D, E

A nurse on the postoperative unit administers many opioid analgesics. Which actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.) a. Avoid using other medications that cause sedation. b. Delay giving medication if the client is sleeping. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia.

C O stands for Outcome that is desired as a result of the work of the QI team.

A nurse participates as part of a quality improvement (QI) team to develop a plan to "reduce deep vein thrombosis on a surgical unit." What part of the PICO(T) question does this statement represent? A. P B. C C. O D. I

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia but no other medical history except well-controlled hypertension and high cholesterol. The client scores a zero. Which action by the nurse is best? a. Assess physiologic indicators and vital signs. b. Do not give pain medication as no pain is indicated. c. Document the findings and continue to monitor. d. Try a small dose of analgesic medication for pain.

A nurse wishes to participate in an activity that will influence health outcomes. What action by the nurse best meets this objective? a. Creating a transportation system for health care appointments b. Lobbying with a national organization for health care policy c. Organizing a food pantry in an impoverished community d. Running for election to the county public health board

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care. b. Ensures that all the client's basic needs are met. c. Tells the client and family about all upcoming tests. d. Thoroughly orients the client and family to the room.

A, B, C, E, F

A nurse wishes to work in a community-based practice setting. Which areas would this nurse explore for employment? (Select all that apply.) a. Hospice facility b. "Minute clinic" c. Mobile mammography unit d. Small community hospital e. Telehealth f. Home health care

A nurse working in a medical home would do which of the following as part of the job? a. Advocate with insurance companies. b. Coordinate interprofessional care. c. Hold monthly team meetings. d. Provide out-of-network specialty referrals.

A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client's blood pressure taken by the AP was much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the AP knew how to take blood pressure b. Double-checking the AP by taking another blood pressure c. Providing more appropriate supervision of the AP d. Taking the blood pressure instead of delegating the task

C, D, E

A postoperative client has an epidural infusion of morphine and bupivacaine. Which actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Ask the client to point out any areas of numbness or tingling. b. Determine how many people are needed to ambulate the client. c. Perform a bladder scan if the client is unable to void after 4 hours. d. Remind the client to use the incentive spirometer every hour. e. Take and record the client's vital signs per agency protocol.

C The intravenous route is the best choice for fast relief of nausea and pain.Oral pain medication may exacerbate the client's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes.

A postoperative client is vomiting and states, "I am having a lot of pain—a 7 on a scale of 0-10." Which route of administration will the nurse choose to administer an analgesic to the client? A. Oral B. Rectal C. Intravenous D. Transdermal

A registered nurse is caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further education on pain control with PCA? a. Assesses the client's pain level per agency policy. b. Monitors the client's respiratory rate and sedation. c. Presses the button when the client cannot reach it. d. Reinforces client teaching about using the PCA pump.

B kg = 2.2 lb. 1 kg of water = 1 L (1000 mL) of water. 14 lb divided by 2.2 = 6300 g (6300 mL).

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy? A. 3000 B. 6300 C. 9300 D. 7000

A, B, C, D

According to the WHO, what does primary care involve? (Select all that apply.) a. Empowered people and communities b. Essential public functions c. Multisectoral policy and action d. Primary care e. Priority consideration of chronic diseases f. Elimination of chronic diseases

C, D

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

C The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia and may require immediate action. All other clients listed have less urgent problems and do not require immediate assessment.

After receiving the change-of-shift report, which client does the nurse assess first? A. A 67 year old with nausea and vomiting who reports abdominal cramps. B. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. C. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. D. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots

After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. "I will drink at least three glasses of milk each day." b. "I will eat three well-balanced meals and a snack daily." c. "I will not take pain medication and antihistamines together." d. "I will avoid salting my food when cooking or during meals."

C P stands for Plan, D stands for Do, S stands for Study, and A stands for Act. Piloting a new protocol would occur during the S step so that the QI team could test it for effectiveness before adopting it as standard policy.

As a result of work completed by a quality improvement (QI) team, a new nursing protocol for preventing catheter-associated urinary tract infections (CAUTIs) is piloted. Which step of the PDSA (Plan, Do, Study, Act) QI model is associated with this action? A. P B. D C. S D. A

B, C, D, F When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, hypotension, and fatigue. Clients with acidosis have problems associated with decreased excitable tissues, including hypotension and decreased perfusion, impaired memory and cognition, increased risk for falls, and reduced neuromuscular responses (not hyperactive deep tendon reflexes). The pH will be below 7.35, which is a characteristic of acidosis. Acute confusion occurs because of reduced gas exchange and reduced cognition.

For which signs and symptoms will the nurse assess in a client who has acute respiratory acidosis with a PaCO2 level of 88 mm Hg? (Select all that apply.) A. Hyperactive deep tendon reflexes b. Acute confusion C. Lethargy D. Hypotension E. pH 7.49 F. Tall T-waves

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema? A. Foot and ankle A. Forehead B. Sacrum C. Chest

B The nurse will respond by indicating that the client's desires about analgesia are the most important consideration in this scenario, and so he would be consulted initially about his family's request. This open-ended type of question acknowledges the family, while keeping the client as the major decision maker.Although the health care provider might have an opinion about the family's request, pain is subjective, and the client's desires about analgesia are the most important consideration. Telling the family that the father's pain control is more important than their concerns is a demeaning response, although technically true; it is dismissive of the family and is nontherapeutic. Giving the family control of pain relief for their father is inappropriate in this situation; the subjective nature of pain places decisions about the use of analgesia with the client who is experiencing the pain. The family and the client may need to make adjustments, but reducing pain relief for the client is not an advisable way to accomplish this goal.

The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond? A. "Yes, this is a valuable way for all of you to make needed adjustments." B. "Let's ask your father about your request." C. "No, his pain relief is more important than your concerns." D. "I will ask his oncologist about your question."

The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment one hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team

The new nurse asks the preceptor how context affects clinical judgment. What response by the preceptor is best? a. "Context considers the whole of the patient's story and circumstances." b. "It shouldn't, only nursing knowledge would affect clinical judgment." c. "Outside influences such as environment in which you provide care, influence your decisions." d. "The context of the situation provides an extra layer of complexity to consider."

The nurse caring for a client with malnutrition assesses which laboratory value as the priority? a. Albumin b. Prealbumin c. Prothrombin time d. Serum sodium

A, D, E

The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? Select all that apply. A. Quality Improvement B. Ethics C. Health Care Disparities D. Systems Thinking E. Teamwork and Collaboration

The nurse in the emergency department (ED) is caring for four clients. Which client does the nurse assess for gas exchange abnormalities first? a. Involved in motor vehicle crash, has broken femur. b. Brought in unconscious by roommate after opioid overdose. c. Asthmatic client being discharged after bronchodilator therapy. d. History of COPD, presents to ED after being bitten by a dog

The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a client. Which information provided by the nurse is most appropriate for the client's long-term outcome? a. "At least you know that the pain after surgery will diminish quickly." b. "Discuss acceptable pain control after your operation with the surgeon." c. "Opioids often cause nausea but you won't have to take them for long." d. "The nursing staff will give you pain medication when you ask them for it."

C Asking when the pain occurs helps determine precipitating factors to identify the source of pain. It is an open-ended question that requires a descriptive response and allows the nurse to obtain the most data.Asking if someone hurt the client may be appropriate in rare circumstances, but typically it is not an appropriately focused question; the question does not relate to the severity or character of the pain. Further, this is not an open-ended question. The nurse should ask the client open-ended questions, not questions requiring a "yes-or-no" answer, such as "Does it feel like sharp pain?" Asking "Is the pain really that bad?" minimizes the client's perception of pain; it is also a closed-ended question requiring a "yes-or-no" answer.

The nurse is assessing a client for acute or persistent pain. What nursing question allows the nurse to obtain the most data from the client? A. "Is the pain really that bad?" B. "Does it feel like sharp pain?" C. "When does the pain occur?" D. "Did someone do this to you?"

The nurse is assessing a client who smokes and consumes fast food several times daily. Which assessment finding requires immediate nursing intervention? A.Cool, pale feet B.Temperature of 99.9° F C.Body mass index of 34 D.Cat allergy that causes shortness of breath

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. "Are you worried about addiction to pain pills?" b. "Do you attach any spiritual meaning to pain?" c. "How high would you say your pain tolerance is?" d. "What pain rating would be acceptable to you?"

B The client at the end of life is dying. The most important intervention for the nurse and interprofessional health care team is to ensure that the client is comfortable. The client will most likely eventually not eat or drink and will have breathing problems as death becomes more near. Coping is important but is not the priority.

The nurse is caring for a client at end of life. What is the nurse's priority for the client's care? A. Promote coping. B. Increase comfort. C. Ensure adequate nutrition. D. Maintain breathing.

B A priority collaborative problem for a client diagnosed with bowel and bladder incontinence is risk for tissue damage and impaired skin integrity. Stool and urine can cause skin irritation, fungal infection, and/or skin breakdown, which are very uncomfortable. Loss of bladder and bowel control can also lead to depression and anxiety.There is no indication that imbalanced nutrition is a problem for this client. Decreased fluid volume and altered level of consciousness are not issues indicated in this client scenario.

The nurse is caring for a client diagnosed with bowel and bladder incontinence. Which is a priority collaborative problem for this client? A. Indequate nutrition B. Impaired skin integrity C. Altered level of consciousness D. Decreased fluid volume

C The priority nursing action is to administer a dose of naxalone 0.4 mg IV. For an unresponsive client, the nurse would administer naloxone 0.4 mg over a 2-minute time period to reverse the action of the opioid analgesic.The order may need to be altered or changed, but calling for a medication order change is not the first action that the nurse would take in an unresponsive client. Nurses do not change orders in terms of dosage or frequency; the health care provider changes the order. A sedated client will not be able to complete a cognitive assessment, and this action would waste time that should be spent on reversing the effects of hydromorphone.

The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What is the priority nursing action? A. Perform a cognitive assessment on the client. B. Call the care provider for a change in the medication order. C. Administer a dose of naloxone 0.4 mg slow IV push. D. Change the order to every 6 hours rather than every 4 hours.

A Delirium is an acute confusional state which usually has a specific cause, such as drug therapy, surgery, relocation, and so forth. The focus of managing this problem is to remove or treat the causative factor(s). The other choices are correct about dementia, a chronic confusional state.

The nurse is caring for a client who has delirium. Which statement is correct regarding this health problem? A. The focus of managing delirium is to treat the cause. B. Delirium takes months to years to develop. C. The cause of delirium is not known. D. Validation therapy is the best approach for delirium.

D Immobility can cause urinary stasis and the development of urinary or renal calculi. Decreased mobility or total immobility for several days can cause serious and often life-threatening complications affecting every body system.Immobility slows gastric motility causing constipation, not increasing it to result in diarrhea. Immobility also does not cause hypertension. Immobility causes muscle atrophy, not hypertrophy.

The nurse is caring for a client who is immobile. The client is most at risk to develop which complication? A. Hypertension B. Muscle hypertrophy C. Diarrhea D. Renal calculi

C The nurse's primary role in pain management is to advocate for the client by accepting reports of pain, as such, this is the nurse's first action. This has become the clinical definition of pain worldwide and reflects an understanding that the client is the authority and the only one who can describe the pain experience.

The nurse is caring for a client who reports pain. As an advocate for the client, what will the nurse do first for this client? A Assess the level of pain. B. Administer pain medication. C. Accept the client's report of pain. D. Call the health care provider for a medication order.

A, B, D, E Cellulitis is an inflammation of skin and underlying tissues. The cardinal signs and symptoms of inflammation are redness, warmth, swelling, and discomfort or pain.

The nurse is caring for a client who was bitten by a spider and has cellulitis. What signs and symptoms would the nurse expect? A. Redness B. Discomfort C. Necrosis D. Warmth E. Swelling

A, B, C

The nurse is caring for a client with severely impaired mobility. What actions does the nurse place on the care plan to address potential complications? (Select all that apply.) a. Perform a depression screen once a day. b. Consult physical therapy for range of motion. c. Increase fiber in the client's diet. d. Decrease fluid intake. e. Allow client to stay in a position of comfort.

The nurse is caring for four clients. Which individual does the nurse identify at highest risk for a cognitive concern? A.29-year-old with a common cold and an ankle fracture B.40-year-old who just received a tetanus immunization after stepping on a rusty nail C.59-year old with diabetes who is meeting with the registered dietician nutritionist (RDN) D.71-year-old who drinks 6 beers daily and had surgery under general anesthesia this morning

D The step of the CJMM that correlates with analysis in the nursing process is to prioritize hypothesis. Also, within this step is analyzing cues. Recognizing cues is assessment, generating solutions is planning, and taking action is implementation.

The nurse is comparing the clinical judgment measurement model (CJMM) and the nursing process. Which step of the CJMM is specific to analysis? A. Generate solutions B. Take actions C. Recognize cues D. Prioritize hypothesis

The nurse is conducting assessments for clients at potential risk for Infection. Which population is most at risk for acquiring an Infection? A. A client who had an open incision for abdominal surgery B. A client who has not been immunized for pneumonia or influenza C. A client who works in a high-stress job for an accounting practice D. A client who is 85 years old and in good health

B, C, D, E

The nurse is delegating ambulation for a client to an experienced Patient Care Technician (PCT). Which teaching will the nurse provide to the UAP? (Select all that apply.) A."Come and get me for lunch." B."Ambulate the client every four hours." C."Each ambulation should last 10 minutes." D."Please let me know how the client does after each ambulation." E."Be certain to use a gait belt when performing this activity."

D Community health care incorporates the model of primary care delivery with a population-based approach. It is within this system of care, at the community health center level, that the most people can be immediately reached in order to receive a new vaccine first. Later, the vaccine may be introduced at specialized points of care such as inpatient care, long-term care, and the medical home.

The nurse is designing a program to make vaccines available to as many people as possible. Into which environment is the vaccine most likely to be introduced first? A. Medical home B. Inpatient care C. Long-term care D. Community Health Center

A, C, D, E The most important part of the CJMM is that another layer—the context of the situation—considers and supports clinical judgment. The factors within this layer, such as environment, time pressure, availability or content of electronic health records, resources, and individual nursing knowledge, have a direct impact on clinical judgment.

The nurse is discussing how context influences clinical judgment. What nursing considerations reflect context? (Select all that apply.) A. Environment of care B. Taking a client's temperature C. Availability of electronic health records D. Time pressures within the unit E. Individual nursing knowledge

A, D, E Pain can be described as belonging to one of four categories related to its location: localized, projected, referred, and radiating. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Referred pain is felt in an area distant from the site of painful stimuli. Radiating pain is felt along a specific nerve or nerves.Pain rated as a 4 on a scale of 0-10 describes the intensity of the pain, not the location. Sharp pain describes the quality of the pain, not the location. Negative vocalization is an indicator of the presence of and quality of pain in adults with dementia.

The nurse is documenting a pain assessment. Which pain descriptions document the location of pain? (Select all that apply.) A. Localized pain B. Sharp pain C. Negative vocalization D. Radiating pain E. Referred pain F. Pain rated as a 4 on a scale of 0-10.

A Social determinants of health include availability of resource to meet daily needs, such as healthful foods.Physical determinants of health include physical barriers or access (such as an access ramp), exposure to toxic substances and other physical hazards, and access to worksites, schools, and recreational settings.

The nurse is evaluating factors that influence care for a client with diabetes. Which client statement does the nurse identify that reflects a social determinant of health? A. "The grocery store in my neighborhood went out of business." B. "The landlord of my apartment is putting in an access ramp for wheelchairs." C. "I work with a lot of toxic chemicals in my job." D. "Because I live on the bus line, I can ride over to park if I want to get fresh air."

A, C, D, E All of these questions are culturally sensitive and respectful to the client with the exception of option C. The nurse would not judge the client and assume that the client is having "problems."

The nurse is interviewing a transgender client about sexual orientation, gender identity, and health care. Which questions are appropriate as part of the interview? (Select all that apply.) A. "Have you disclosed your gender identity and sexual orientation to your primary health care provider?" B. "Do you have problems being accepted because you are different?" C. "If you have more than one sexual partner, how are you protecting both of you from infections?" D. "Do you have sex with men, women, both, or neither?" E. "Are you in a relationship with someone who lives with you?"

The nurse is participating in a unit meeting to discuss daily nursing care expectations. Which nursing statement reflects systems level thinking? a) "It is important to provide care consistent with the client's expectation." b) "I will always consider my client's cultural preferences when delivering care." c) "I have been comparing our rates of infection with other units in the hospital."* d) "I will look for the policy about family visitation to show my client."

B The nurse will change the dressing at 4:30 p.m. About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a client. At 4:30 p.m., the opioid has had time to take effect and provide relief for the client.It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 p.m.), because the pain medication will be at its lowest concentrations in the client's system. At 4:00 p.m., the analgesic has not had time to enter the client's system, so it is too soon to perform the dressing change. If the client received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 p.m. to facilitate a dressing change with minimal discomfort.

The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? A. 3:30 p.m. B. 4:30 p.m. C. 4:00 p.m. D. 7:00 p.m.

A, B, C, D, E The nurse would likely collaborate with all of these health care team members to prevent complications of decreased mobility, and promote an increase in or maintain the current level of mobility if possible.

The nurse is planning care for a client who has decreased mobility. With which interprofessional health care team members would the nurse most likely collaborate? Select all that apply. A. Registered dietitian nutritionist (RDN) B. Registered occupational therapist (OTR) C. Primary health care provider (PHCP) D. Respiratory therapist (RT) E. Registered physical therapist (RPT)

D The occupational therapist helps clients develop, recover, improve, and maintain ADLs through therapy. The physical therapist uses treatment techniques to promote movement, reduce pain, restore function, and prevent disability. The licensed social worker helps clients solve and cope with problems in their everyday lives. Assistive personnel assist clients with ADLs, but do not help them to improve skills to perform ADLs.

The nurse is providing care for a client who recently had a brain attack. Which member of the interprofessional health care team does the nurse identify that can help the client improve skills to perform ADLs? A. Assistive personnel B. Physical therapist C. Licensed social worker D. Occupational therapist

A, B, C, E, F All of these groups have problems with adequate immunity either due to advanced age, illness, substance use, or lack of healthy lifestyle practices. Not being immunized for influenza is also a poor health practice.

The nurse is providing health teaching at a health fair about preventing influenza. What adult groups are at risk for contracting this disease due to altered immunity? (Select all that apply.) A. Nonimmunized adults B. Adults who do not practice a healthy lifestyle C. Adults with substance use disorder D. Women who are pregnant E. Older adults F. Adults with chronic illness

C Clinical judgment, as defined by the National Council of State Boards of Nursing, is the observed outcome of critical thinking and decision making. It is an iterative process (not fixed) that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.

The nurse is teaching a class on clinical judgment. What teaching will the nurse include? A. Clinical judgment is a fixed process. B. Clinical judgment is not required to make an informed decision. C. Clinical judgment is an outcome of critical thinking. D. Clinical judgment happens outside the context of the scenario.

The nurse is teaching a class on pain management strategies. Which client statement requires additional teaching? A. "Persistent pain is a warning in my body that alerts the sympathetic nervous system." B. "Acute pain has a quick onset and is usually isolated to one area of my body." C. "My frozen-shoulder causes musculoskeletal or somatic pain." D. "Nociceptive pain follows a normal and predictable pattern."

B, E, F Systems thinking pushes the nurse to look beyond the individualized client to consider the impacts within the health care system as a whole. Systems thinking does allow the nurse to consider the root problems that affect care and fosters interprofessional care. Systems thinking does not shift away from safety, rather it promotes safety through quality-based care. The complexity of care and health policy as local, state, national, and global levels can affect systems thinking.

The nurse is teaching a class on systems thinking in nursing. What teaching will the nurse include? (Select all that apply.) A. Systems thinking is not affected by health policy at the national level. B. The complexity of client care can affect systems thinking. C. Systems thinking shifts the focus from safety to quality in care. D. It is important for the nurse to place all focus on individualized client care. E. Systems thinking allows the nurse to assess the root of problems. F. Interprofessional, collaborative care is fostered when using systems thinking.

A, D, F Methods to promote cognition include encouraging senior citizens to stimulate the intellectual part of their brain through new learning activities such as taking music lessons, mastering a new language, or completing crossword puzzles or other "brain teasers."Playing cards, reading the newspaper, and watching television are not new learning activities that could stimulate the intellectual part of the brain.

The nurse is teaching a health and wellness class at a local senior citizen center. When discussing methods to promote cognition, which options would be included? (Select all that apply.) A. Take music lessons. B. Watch television. C. Read the newspaper. D. Complete crossword puzzles. E. Play card games. F. Learn a new language.

B, C, D, E Risk factors that increase the probability of impaired cellular regulation include smoking, poor nutrition, lack of physical activity, and an age greater than 50. Also, those clients greater than 70 years of age have a significant potential for abnormal cell development.Alcohol intake is not associated with impaired cellular regulation.

The nurse is teaching a health and wellness class. What would the nurse include in the discussion of common risk factor for impaired cellular regulation? (Select all that apply.) A. Drinking alcohol B. Smoking C. Over the age of 70 D. Poor nutrition E. Physical inactivity

A, B, E Cannabis is a schedule I controlled substance and has been since 1970. Federal and state law often vary in the legality of cannabis use. A health care provider cannot prescribe cannabis in any state; however, they may assess and determine whether a client has a qualifying condition in accordance with state law. Side effects of cannabis include: increased heart rate, increased appetite, dizziness, decreased blood pressure, dry mouth, hallucinations, paranoia, altered psychomotor function, and impaired attention. The psychoactive component, THC, is not removed from medical cannabis.

The nurse is teaching the client about the use of medical marijuana. What teaching will the nurse include? (Select all that apply.) A. "Medical cannabis is a controlled substance in the United States". B. "Federal and state law often vary in the legality of medical cannabis use." C. "The psychoactive component of medical cannabis is removed." D. "Your health care provider can prescribe cannabis for you." E. "Side effects of cannabis can include dizziness and increased appetite."

A, C, D, E

The nurse manager is conducting an annual evaluation of a staff nurse and is appraising the nurse's clinical reasoning. What nurse actions does the manager observe to help form this judgment? (Select all that apply.) a. Anticipating consequences of actions b. Delegating appropriately c. Interpreting data d. Noticing cues e. Setting priorities

C The client is displaying the signs and symptoms of an acute arterial clot that is preventing adequate perfusion to the left leg. This is an emergent situation which requires the nurse to contact the RRT immediately.

The nurse notes that a client has a pale cool left leg without palpable pulses. What would be the nurse's best action at this time? A. Continue to monitor the client's left leg. B. Document the assessment findings. B. Contact the Rapid Response Team (RRT). D. Elevate the client's left leg.

The nurse observes that numerous clients on a medical-surgical respiratory unit seem to have increasingly frequent readmissions. What quality improvement step could the nurse implement to explore the readmission rate? A.Inform the unit manager of the concern. B.Evaluate trends and develop a plan for improvement. C.Contact the hospital quality improvement nurse to create an improvement strategy. D.Post a journal article on the unit that addresses national readmission rates for respiratory disorders.

A, B, E, F In a discussion at a health fair about promoting a healthy gut and preventing constipation, the nurse would include advice about not ignoring the urge to defecate, establishing a regular exercise routine, and increasing the amount of fresh fruits and vegetables in the diet. Maintaining normal elimination requires adequate nutrition and hydration. People with, or at risk for, constipation should be taught to promptly toilet when the urge occurs, exercise to stimulate peristalsis, eat a diet high in fiber (found in fruits, vegetables, and whole grains) and to drink 8 to 12 glasses of water (2000 to 3000 mL) each day unless medically contraindicated.Fiber needs to be increased, not decreased. Also, clients with constipation may need to take bulk-forming agents or stool softeners in addition to a high-fiber diet and fluids. However, they do not need to take them regularly.

The nurse prepares a presentation on promoting a healthy gut at a health fair. Which information should the nurse include to prevent constipation? (Select all that apply.) A. "Increase the amount of fresh fruits and vegetables in diet." B. "Do not ignore the urge to defecate." C. "Use over-the-counter laxatives frequently." D. "Decrease the amount of fiber in diet." E. "Maintain fluid intake of at least 2000 mL/day." F. "Establish a regular exercise routine."

A, B, C, D, E All of these actions are important to prevent venous stasis which can lead to deep vein thrombosis except for option B. Clients who have a decreased ability to clot would experience unusual bleeding and bruising.

The nurse prepares to teach a client at risk for increased clotting about interventions to prevent clots. What health teaching would the nurse include? (Select all that apply.) A. "Avoid prolonged periods of sitting." B. "Walk around frequently as much as you can." C. "Avoid crossing your legs when sitting." D. "Drink plenty of fluids, including water." E. "Seek smoking cessation programs if needed." F. "Report any unusual bleeding or bruising."

The nurse provides an SBAR handoff communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format? A. Situation B. Background C. Assessment D.Recommendation

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly" asking for more pain medication. When assessing this client's pain, which statement or question by the nurse is most appropriate? a. "Help me understand how pain is affecting you right now." b. "I wish I could do more; is there anything I can get for you?" c. "You cannot have more pain medication for 3 hours." d. "Why do you think the medication is not helping your pain?"

B The competency of Interprofessional Communication is the ability to communicate with patients, families, and other health professionals in a way that supports a team approach to maintaining health and managing health problems. Values/Ethics relates to respect for the health care team, Role-Responsibilities uses knowledge of one's own role to manage patients, and Teams and Teamwork involves actual delivery of care with the health team.

The nurse requests a conference with members of the interprofessional health care team regarding care for a complex client. Which Interprofessional Education Collaborative Competency does this request represent? A. Role-Responsibilities B. Interprofessional Communication C. Values/Ethics for Interprofessional Practice D. Teams and Teamwork

The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality with clients, especially those who are older. What suggestion by the staff development nurse is most appropriate? a. "Find a trusted friend and role play." b. "Don't worry it will get easier." c. "A sexual assessment is usually not needed." d. "It's hard for me to do, too."

The nurse understands which information regarding patient-centered care? a. A competency recognizing the client as the source of control of his or her care b. A project addressing challenges in implementing patient-centered care c. Purposeful, informed, and outcome-focused care of clients or families d. The ability to use best evidence and practice when making care-related decisions

B, C, D, E

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurse's expertise c. Client preferences d. Research findings e. Values of the client f. Plan-do-study-act model

A, B, C, D, G Pain Assessment in Advanced Dementia (PAINAD) scale has been tested in patients with severe dementia (Herr et al., 2011). The tool groups behavioral indicators into five categories for scoring using a graduated scale of 0 (least intense behaviors) to 2 (most intense behaviors) per category for a maximum behavioral score of 10:· Breathing (independent of vocalization)· Negative vocalization· Facial expression· Body language· Consolability (ability to calm the patient)Picking at the skin or clothing as well as ability to distract the client are not portions of the PAINAD scale.

The nursing is using the pain assessment in advanced dementia pain scale to assess a client. What categories of pain indicators will the nurse assess? (Select all that apply.) A. Body language B, Facial expression C. Breathing pattern D. Ability to calm the client E. Ability to distract the client F. Picking at skin or clothing G. Vocalizations

The registered nurse asks the nursing assistant why a cardiac client's morning weight has not yet been done. The nursing assistant says, "I'll get to it, what's the big deal?" When deciding how to respond, the nurse considers what information about weight? a. Decisions on treatment often depend on the daily weight. b. The nursing assistant needs to ensure that tasks are done on time. c. Weight is the most accurate noninvasive indicator of fluid status. d. A change in weight may indicate the need to change IV fluids.

To demonstrate clinical reasoning skills, what action does the nurse take? a. Collaborating with co-workers to buddy up for lunch breaks b. Delegating frequent vital signs on a new postoperative patient c. Documenting a complete history and physical on an admission d. Requesting the provider order medication for a client with high potassium

C Expanding telehealth (including telenursing) is a goal for Healthy People 2030 and is expanding globally to meet the needs of many clients in a cost-effective manner.

What does the nurse recognize is the fastest growing technology being used for informatics? A. Drug information libraries B. Medication bar code administration C. Telehealth and telenursing D. Electronic health record

C The addition of albumin to the plasma would add a colloidal substance that does not move into the interstitial space. Thus, the osmotic pressure would immediately increase. Not only does the additional 200 mL add to the plasma hydrostatic pressure, but also the increased osmotic pressure would draw water from the interstitial space, increasing the plasma volume and ultimately leading to an increased hydrostatic pressure in the plasma volume.

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures? A. Decreased osmotic pressure; decreased hydrostatic pressure B. Decreased osmotic pressure; increased hydrostatic pressure C. Increased osmotic pressure; increased hydrostatic pressure D. Increased osmotic pressure; decreased hydrostatic pressure

What factor best predicts a nurse's willingness to employ critical thinking? a. Caring b. Knowledge c. Presence d. Skills

D The normal range for serum chloride levels is between 98 and 106 mEq/L. No action beyond confirming documentation is needed.

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? A. Urge the client to drink more water. B. Notify the primary health care provider. C. Assess the client's deep tendon reflexes. D. Document the finding as the only action.

A, B, C, D, E

What is the generalist registered nurse's role related to patient care within a system? Select all that apply. A. Caring* B. Teaching* C. Collaborating* D. Advocating* E. Researching* Prescribing

A Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions occurring during blood pressure measurement are indicative of hypocalcemia and referred to as a positive Trousseau sign. Initiating the Rapid Response Team is a good second action. Placing the client in high-Fowler position will not help the hypocalcemia.

What is the nurse's best first action when a client's hand goes into flexion contractures during blood pressure measurement with an external cuff? A. Deflating the blood pressure cuff and giving the client oxygen B. Documenting the finding as the only action C. Initiating the Rapid Response Team D. Placing the client in the high-Fowler position and increasing the IV flow rate

D In human physiology and homeostasis, free hydrogen ions and carbon dioxide levels are directly related. Any condition that changes the concentration of one always causes a corresponding change in the concentration of the other in the same direction. Carbon dioxide is not a buffer and does not directly bind free hydrogen ions.

What is the relationship between free hydrogen ions and carbon dioxide? A. An increase in free hydrogen ions always lowers carbon dioxide levels. B. Carbon dioxide can bind free hydrogen ions to increase the pH. C. Carbon dioxide can bind free hydrogen ions to decrease the pH. D. An increase in free hydrogen ions always increases carbon dioxide levels.

C The action of aldosterone, known as the water- and sodium-saving hormone, increases the kidney reabsorption of both water and sodium to maintain blood volume and osmolarity. Clients who have low levels of aldosterone secretion lose large amounts of sodium and water in the urine, which results in low blood volume and low blood osmolarity.

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low? A. Decreased blood volume; increased blood osmolarity B. Increased blood volume; decreased blood osmolarity C. Decreased blood volume; decreased blood osmolarity D. Increased blood volume; increased blood osmolarity

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1 hour time period? A. Plasma volume osmolarity increases; blood pressure increases B. Plasma volume osmolarity decreases; blood pressure increases C. Plasma volume osmolarity increases; blood pressure decreases D. B. Plasma volume osmolarity decreases; blood pressure decreases

D The best evidence-based nursing practice will be developed by using information from randomized controlled studies testing the impact of various nursing interventions on outcomes for clients with pneumonia. This type of data collection is the most scientifically based approach listed here. Articles in nursing magazines are likely to be researcher biased. They are also unlikely to be controlled. Chart review serves as a limited source of data and cannot be generalized for a standard. Also, regional practices may tend to skew the data. Data from nurses, although valuable, are likely to be biased; data collection would not be well controlled.

When developing a standardized plan of care for clients with a diagnosis of pneumonia, how does the nurse find the best information about providing optimal nursing care? A. Survey experienced RNs about which nursing actions are effective when caring for clients with pneumonia. B. Research the most recent articles in nursing magazines that discuss care for clients with pneumonia. C. Review the chart to determine what primary health care provider's prescriptions are frequently written for clients with pneumonia. D. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia.

A, B, F Normal metabolic functions such as metabolism of carbohydrates, proteins, and fats for fuel all result in products that contribute to the free hydrogen ion concentration. Hydrochloric acid in the stomach is broken down into free hydrogen ions and chloride ions. Exercising muscles produce some lactic acid, which also contributes to normal hydrogen ion production. The hydrogen ions present in the urine during a urinary tract infection are produced by the bacteria, not the kidney. Greenhouse gases are not a normal source of free hydrogen ions and neither is the ingestion of spicy foods.

Where do free hydrogen ions normally come from in the human body? (Select all that apply.) A. Free hydrogen ions are produced by-products of carbohydrate and protein metabolism. B. Heavy exercise and muscle work produce hydrogen ions in the form of lactic acid. C. Ingestion of spicy food increases the concentration of uncontrolled free hydrogen ions. D. The kidney produces hydrogen ions when a urinary tract infection is present. E. Humans breathe in free hydrogen ions in the atmosphere from the buildup of greenhouse gases. F. Hydrochloric acid is produced in the stomach and is a normal source of free hydrogen ions.

A The tight eschar on the chest can limit chest movement and make breathing less effective with hypoventilation. This problem results in inadequate oxygenation and retention of carbon dioxide, causing respiratory acidosis. Respiratory alkalosis is caused by hyperventilation, increased rate or depth of breathing, causing carbon dioxide to be eliminated in excess. Metabolic acid-base disturbances are usually caused by nonrespiratory issues.

Which acid-base disturbance will the nurse remain alert for when caring for a client who has chest burns with tight eschar banding the chest? A.; Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A A ventilator set at either too high a ventilation rate and/or at too great a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid-deficit respiratory alkalosis.

Which acid-base problem does the nurse expect when the ventilator of a client being mechanically ventilated is set at too high a rate of breaths per minute for 6 hours? A. Acid deficit alkalosis B. Base excess alkalosis C. Acid excess acidosis D. Base deficit acidosis

D The severe acidosis seen immediately following a grand mal seizure is both respiratory and metabolic in origin (a combined acidosis). The client does not breathe during the actual seizure, which causes a huge retention of carbon dioxide (respiratory acidosis). The carbon dioxide level is very high because the seizing muscles are working hard under anaerobic conditions creating lots of lactic acid and hydrogen ions (metabolic acidosis), which are then converted to carbon dioxide through the carbonic anhydrase reaction. If the client stops having seizure activity, he or she will return to acid-base balance without intervention. This return occurs earlier when oxygen is applied. Bicarbonate is not lost during a seizure and most definitely should not be replaced. Hydration and insulin do nothing to restore acid-base balance in this situation.

Which action does the nurse expect is most likely to help restore acid-base balance in a client whose arterial blood pH is 7.17 immediately after a grand mal seizure? A. Administering bicarbonate orally or intravenously B. Providing hydration with IV normal saline C. Administering insulin D. Applying oxygen

D The client has hyperkalemia. The nurse must initiate continuous cardiac monitoring for this client because hyperkalemia can lead to life-threatening bradycardia and other dysrhythmias, including tall, peaked T waves; prolonged PR intervals; flat or absent P waves; wide QRS complexes; and possible ectopic beats. Monitoring allows the nurse to determine whether therapy is effective or if the client's condition is worsening. Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about which foods to avoid are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? A. Teaching the client which foods to avoid B. Administering sodium polystyrene sulfonate orally C. Collaborating with the registered dietitian nutritionist to provide a potssium-restricted diet D. Initiating continuous cardiac monitoring

D Pulmonary edema with difficulty breathing can develop quickly in clients with fluid overload. Although assessing whether other signs and symptoms of fluid overload is important, the priority is to ensure adequate gas exchange before taking any other action. Raising the head of the bed takes little time and can help improve gas exchange even when pulmonary edema is present.

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload? A. Checking for presence of dependent edema B. Assessing blood pressure C. Measuring intake and output D. Elevating the head of the bed

C, F

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) A. Keeping the client NPO during drug treatment B. Pushing the drug as a bolus slowly over 5 minutes C. Using an IV controller to deliver the drug D. Checking IV access for blood return after the infusion E. Initiating the IV in a hand vein for rapid access F. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

A Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care would be assigned to the LPN/LVN. LPN/LVN education and scope of practice include working within practice parameters to administer pain medication and to perform dressing changes.Assessments and client education are not within the LPN/LVN scope of practice.

Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? A. Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care B. Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief C. Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable D. Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain

D The most sensitive indicator of an adequate fluid volume is increasing urine output. The fact that a client who is dehydrated now has an hourly urine output of more than 15 mL is a positive indicator that the therapy is effective. Decreasing pulse pressure and a hematocrit above normal are indicators of on-going dehydration. Appetite is not a true indicator of hydration status.

Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful? A. Pulse pressure has decreased. B. Client reports feeling hungry. C. Hematocrit is 58% (0.58 volume fraction). D. Hourly urine output is greater than 15 mL.

B Neck veins are normally distended when a client is in the supine position and are flat when a client is sitting or standing. When hypervolemia worsens the neck veins are distended even when the client is upright. Hearing breath sounds in the lower lung lobes is a positive sign, not one that indicates the condition is worsening. An unchanged weight indicates the client's condition is stable, not worsening. The color of the ears and nose is not related to hydration status.

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? A. Nose and ears have a slightly yellow-tinged appearance. B. Neck veins are now distended in the sitting position. C. Breath sounds can be heard in the right lower lung lobe. D. Weight is unchanged from that obtained yesterday.

A, C, F

Which assessment findings indicate to the nurse that a client taking warfarin may have decreased Clotting? Select all that apply. A. Frequent nosebleeds B. Lower leg swelling C. Upper extremity bruising D. Difficulty breathing E. Intermittent chest pain F. Dark stools

A, B, D, E Potential causes of hyperkalemia include excessive use of salt substitutes (which contain high levels of potassium), chronic kidney disease (which prevents adequate excretion of potassium), daily use of a potassium-sparing diuretic (reduces potassium excretion), and the use of an angiotensin converting enzyme inhibitor. Neither a vegan diet nor previous illness with hepatitis A is associated with development of hyperkalemia.

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) A. Management of hypertension with an angiotensin converting enzyme inhibitor B. Presence of chronic kidney disease C. Vegan diet D. Excessive use of salt substitute E. Daily therapy with a potassium-sparing diuretics F. Past history of hepatitis A

C Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate because hypotension is a sign/symptom of hypermagnesemia that could occur when too much has infused. Most clients who have fluid and electrolyte problems will be monitored for intake and output; however, changes will not immediately indicate problems with magnesium overdose. Headaches are not associated with hypermagnesemia. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? A. Monitoring 24-hour urine output B. Monitoring the serum calcium levels C. Assessing the blood pressure hourly D. Asking the client whether a headache is present

A Although all assessment actions listed are important, the most critical one to perform is assessing respiratory function effectiveness. Skeletal muscle weakness can make respiratory movements ineffective, leading to respiratory failure and death. Although cardiac changes can occur.

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? A. Checking pulse oximetry B. Measuring blood pressure C. Listening to bowel sounds in all four quadrants D. Observing the ECG for flat T-waves

C When caring for an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure changes. Comparisons of blood pressures obtained with the client lying, then sitting, and finally standing can detect postural changes. If the standing blood pressure is significantly lower than that obtained while the client was in the lying or sitting positions, insufficient blood flow to the brain may cause hypotension with light-headedness and dizziness, which increase the risk for falls.Comparing apical to radial pulse rates does not provide information to detect degree of dehydration. Although assessment of oral mucous membranes can detect symptoms of dehydration, it does not provide information for falls risk. Dehydration usually results in an elevated serum potassium level, not a decreased level.

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation? A. Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) B. Assessing for furrows on the tongue to determine dryness of oral mucous membranes C. Comparing blood pressure measurements in the lying, sitting, and standing positions D. Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

C, D The serum sodium is extremely low, which makes depolarization slower and cell membranes less excitable. It also can cause cerebral edema to form, leading to confusion and seizure activity. When sodium levels become very low, coma and death may occur. Assessing cognition and checking deep tendon reflexes are the most important assessment data to obtain. Monitoring urine output needs to be done but is not the priority action in this situation. Assessing skin turgor, presence of abdominal pain, and fever are not an urgent assessment to prevent immediate harm.

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.) A. Testing skin turgor B. Asking about any abdominal pain C. Assessing cognition D. Checking deep tendon reflexes E. Monitoring urine output F. Checking for the presence of fever

C, E Assess skin turgor in an older client by pinching the skin over the sternum or on the forehead, rather than on the back of the hand. With aging the skin loses elasticity and tents on hands and arms even when the client is well hydrated and thus, changes in these areas are not reliable indicators of hydration status.Many older clients have dry flaky skin on the shins regardless of hydration status. The skin of the abdomen is looser in older clients and also is not a reliable skin area to check hydration status.

Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.) A. Tops of the forearms B. Skin of the shins C. Skin of the forehead D. Skin over the abdomen E. Skin over the sternum F. Back of the hand

C During acidosis, the body attempts to bring the pH closer to normal by moving free hydrogen ions into cells in exchange for potassium ions. This exchange can cause hyperkalemia, which alters all excitable membranes. In the heart, hyperkalemia can block electrical conduction through the heart and cause severe bradycardia and even cardiac arrest. Although all body systems are affected to some degree, the cardiovascular system must be assessed first to institute actions to prevent death.

Which body system will the nurse assess first to prevent harm for a client who has severe metabolic acidosis? A. Gastrointestinal system B. Respiratory system C. Cardiovascular system D. Autonomic nervous system

Which client arterial blood pH value indicates to the nurse the lowest concentration of free hydrogen ions? A. 7.45 B. 7.42 C. 7.36 D. 7.29

Which client arterial blood pH value will the nurse interpret as normal? A. 7.37 B. 7.27 C. 7.47 D. 7.5

A Hypercalcemia affects increases myocardial contractility and slows depolarization. Common ECG changes include wide T-waves and shortened QT-intervals. Bradycardia and heart block may follow.

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? A. Shortened QT-interval B. Absent P wave C. Prominent U wave D. Inverted T waves

B Managed care is a type of organized delivery of care where costs have been determined by the managed care company and health care providers. Therefore, the client whose fixed cost for a physical at $80 is being treated via managed care.Being admitted to a hospital is part of inpatient care. Seeing a designated family physician is part of primary health care. Obtaining vaccinations at a local community health center is part of community health care.

Which client situation reflects the health care system of managed care? A. A client obtains vaccinations at a local community health center that is close to home. B. A client receives an annual physical where the cost has been predetermined as $80. C. A client sees a designed family physician who coordinates all aspects of the client's care. D. A client with abdominal pain is admitted to a hospital for 24 hours of observation.

A Women at any age have a higher risk for dehydration because women have more body fat than men, and fat cells contain practically no water. Men have a higher percentage of total body water at any age because they have more muscle mass than women and muscle cells contain a high concentration of water. The risk for dehydration increases with age. As adults age, their total body water volume decreases because both older men and older women loss muscle mass with aging.

Which client will the nurse consider to be at greatest risk for dehydration?? A. A 75-year-old woman with chronic back pain B. A 25-year-old woman taking oral contraceptives C. A 75-year-old man who has a vitamin deficiency D. A 25-year-old man who has frequent esophageal reflux

C Hyperkalemia occurs as compensation for any type of acidosis, including diabetic ketoacidosis, by having cells take up excess hydrogen ions (from the acidosis) in exchange for releasing intracellular potassium to maintain electroneutrality in both fluid compartments. The client receiving TPN is at risk for metabolic alkalosis due to an increase in base components. Hyperventilation leads to respiratory alkalosis, which causes hypokalemia. Furosemide increases potassium loss, leading to hypokalemia.

Which client will the nurse observe frequently for indications of hyperkalemia? A. A 72 year old receiving total parenteral nutrition B. A 65 year old taking furosemide for chronic heart failure C. A 38 year old being managed for diabetic ketoacidosis D. A 30 year old who has anxiety-induced hyperventilation

B Calcium is absorbed from the gastrointestinal tract under the influence of vitamin D. When a client is malnourished, not only is the dietary intake of calcium usually low, but the client is also vitamin deficient. Hyperparthyroidism would increase serum calcium levels. Neither NSAIDs nor tetracycline increase the risk for hypocalcemia.

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? A. A 26 year old with hyperparathyroidism B. A 70 year old who has alcoholism and malnutrition C. A 40 year old taking tetracycline for an infection D. A 35 year old athlete taking NSAIDs for joint pain

A, D, F

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply. A. Blood pressure B. Deep tendon reflexes C. Hand-grip strength D. Pulse rate and quality E. Skin turgor F. Urine output

C Nasogastric suction results in alkalosis from overelimination of hydrogen ions when stomach hydrochloric acid removed by the continuous suction.

Which condition does the nurse consider as most likely to have caused a client's arterial blood gas value to show an increased pH? A. Water retention B. Partial airway obstruction C. Nasogastric suction D. Diabetic ketoacidosis

C Hyperkalemia affects cardiac conduction inducing tall T-waves, widened QRS complexes, absent P waves, prolonged PR intervals, bradycardia, and heart block. A heart rate that is regular and within the client's normal range for rate indicates resolution of the hyperkalemia. The normal respiratory rate does not indicate resolution of the hyperkalemia. Chvostek sign is present with hypocalcemia, not hyperkalemia. The hematocrit is not affected by hyperkalemia or its management.

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? A. Chvostek sign is negative. B. Respiratory rate is 22 breaths/min. C. Pulse rate is 76 beats/min and regular. D. Hematocrit is 42%.

A, B, C, D Sepsis and hypovolemic shock result in anaerobic metabolism and increased production of carbon dioxide, lactic acid, and free hydrogen ions. When a ventilator is set at too low of a tidal volume for the client's size, hypoventilation occurs with poor gas exchange and retained carbon dioxide. Severe diarrhea causes excess loss of bicarbonate ions in the stool, resulting in a base-deficit metabolic acidosis. Hyperventilation can result in respiratory alkalosis, not acidosis. Prolonged nasogastric suctioning results in a loss of hydrochloric acid and leads to an acid-deficit metabolic alkalosis.

Which conditions could cause a client to develop acidosis? (Select all that apply.) A. Ventilator at too low a tidal volume B. Sepsis C. Severe diarrhea D. Hypovolemic shock E. Prolonged nasogastric suctioning F. Hyperventilation

A, B, C, E

Which environments of care will the nurse recognize as components of the healthcare system? Select all that apply. a) Long term care* b) Primary care* c) Free standing emergency department* d) National League of Nursing e) Patient-centered medical home* f) World Health Organization

A, B, C, D, E. F

Which factor does the nurse identify that impacts clinical judgment? Select all that apply. A.State legislation about marijuana B.Socioeconomic status of the client C.Age of technology in the health care agency D.The number of a client's co-existing conditions E.Access to a database of clinical best practices F.Availability of members of the interprofessional team

A, B, C, D, E, F Knowledge and experience of the health care professional influence client outcomes. Other factors that directly influence client outcomes include:· Behavioral and social determinants of health: What "health" means to each client within the context of his or her culture· New approaches to population health management: evidence-based care that is delivered to individuals, communities, and populations· Policy and health care reform: legislation at all levels of government, which influence health care as a right rather than a privilege· Available and emerging technologies: the use of which assesses for health risks and influences treatment plans· Interprofessional practice: the collaboration of all health care team members who are focused on patient-centered care· Shift towards systems thinking: the recognition that health maintenance, health care activities, and health care interventions do not occur in isolation, and that lessons can be learned from individual care that pertains to a larger group of patients (and vice versa).

Which factor does the nurse identify that influences client outcomes? (Select all that apply.) A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies D. What the individual client believes about health? E. Technology that is available in the local community health center F. The application of systems thinking to care of clients

D When hyponatremia is caused by fluid volume excess, other blood/serum values are low as a result of dilution. The hematocrit level is low, which may be related to hyponatremia. The chloride level is normal. Elevated levels are associated with dehydration and reduced kidney function. The arterial pH is normal.

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? A. Serum chloride level is 100 mEq/L (mmol/L) B. Blood urea nitrogen (BUN) is elevated C. Arterial blood pH is 7.37 D. Hematocrit is 29% (0.29 volume fraction)

Which normal physiologic process contributes most to the need for acid-base balance? A. Continuous organ production of bicarbonate from carbonic acid B. Continuous alveolar exchange of oxygen and carbon dioxide C. Continuous metabolic production of free hydrogen ions D. Continuous kidney formation of urine from blood

A The principle of justice refers to equality—all clients should be treated equally and fairly, as demonstrated by the respect shown to the client with dementia. The 32-year-old's fall prevention relates to providing a safe care environment, which is an important nursing principle but is not categorized as justice. Providing the 82-year-old client access to the hospital Patient Advocate is an example of the principle of self-determination through facilitation of the client's autonomy. Including the parents of the 13 year old in the discussion about care represents an example of dependent care, not the principle of justice. Teens may not legally be empowered as the final decision makers in their own care.

Which nursing action demonstrates use of the principle of justice? A. A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer. B. An 82-year-old client is provided access to the hospital Patient Advocate for processing of a complaint. C. A 32-year-old client is prevented from falling during the initial postoperative period following her hysterectomy. D. The parents of a 13 year old are included in discussions about the course of their teen's treatment and care.

E, F Assessment involves observing what the client says subjectively, and what the nurse observes objectively. Collecting information about how a client sustained an injury and noting a pressure injury are examples of assessment.Comparing temperature readings reflects evaluating.Setting a goal for a client reflects planning.Administering medication reflects implementing.Contacting a health care provider after determining a blood pressure reading is high reflects analyzing, and then implementing.

Which nursing action reflects Assessing, per the AAPIE model of Assessing, Analyzing, Planning, Implementing, and Evaluating? (Select all that apply.) A. Administers IV furosemide 40 mg as prescribed. B. Sets a goal for client to resume normal activities within 4 weeks following surgery. C. Compares temperature at 0600 with temperature taken at 1200. D. Contacts health care provider after obtaining blood pressure of 200/100. E. Collects information about how client sustained an injury. F.Notes pressure injury of 2 inches by 1 inch on sacrum.

B The goal of systems thinking is to encourage the nurse to develop awareness of the interrelationships that exist between individual care and the overall context of health caresafety and quality improvement. Documenting and reporting affect individual patient care. Reviewing best practice reflects improving individual nurse practice. Quality improvement initiatives address the systems level, working to improve assessment within an entire unit and/or facility.

Which nursing action reflects systems thinking? A. Giving report to the next shift including client status B. Developing a quality improvement initiative for respiratory assessment C. Documenting the client's lung sounds each shift D. Reviewing best practices for respiratory assessment

C, D The QSEN competency of Patient-Centered Care recognizes that the client, with his or her own autonomy, is at the center of all decision making related to care. Respecting the client's preferences about treatment, and including the client in discussions about dietary choices, reflects patient-centered care.Designing nursing care with a focus on safety reflects the QSEN competency of Safety.Referring to a nursing journal to consider trends in care reflects the QSEN competency of Evidence-Based Practice.Participating on a committee that is evaluating the newest bar-code scanner reflects the QSEN competencies of Evidence-Based Practice and Teamwork and Collaboration.Using data collected over the past quarter to determine if and how nursing care should change reflects the QSEN competency of Quality Improvement.

Which nursing action reflects the QSEN competency of Patient-Centered Care? (Select all that apply.) A. Designing nursing care with a focus on keeping the client safe B. Participating on a committee that is evaluating the newest bar-code scanner C. Including the client in discussions about dietary choices D. Respecting the client's preference about treatment options E. Referring to a nursing journal to consider trends in care F. Using data collected over the past quarter to determine if and how nursing care should change

A Prioritizing hypotheses is the act of considering all possibilities and determining their relative urgency and risk to the client. The nurse who has determined that a blood pressure reading of 190/100 requires nursing intervention now has performed prioritization.Administering medication and contacting a member of the interprofessional health care team reflects the CJMM process of take action. Obtaining vital signs and noting the reading reflects the CJMM process of recognize cues.

Which nursing action reflects the process of prioritize hypotheses, per the NCSBN Clinical Judgement Measurement Model (CJMM)? A. Determining that a new blood pressure reading of 190/100 requires intervention now B. Obtaining vital signs every 4 hours and noting a client's blood pressure as 130/90 C. Administering amlodipine 5 mg orally once daily D. Contacting the registered dietician nutritionist (RDN) to evaluate a client's salt intake

B, E

Which nursing activities may be safely delegated to competent assistive personnel (AP)? Select all that apply A. Discharge Teaching B. Blood pressure monitoring C. Gastrostomy feeding D. Oxygen administration E. Ambulation assistance

Which nursing documentation demonstrates the integration of patient-centered care? A. Social worker paged for consultation B. Steady gait observed when ambulating C. Discussed dietary preferences with client D. Nursing literature reviewed for best practice approaches

C The case manager role includes coordination of acute care and postdischarge community services for the client. The physical therapist, health care provider, and unit-based RN will have input into planning for rehabilitation for the client, but are not the best choice to coordinate a smooth transition from acute care to community rehabilitation services.

Which of these hospital staff members will the nurse manager request to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury? A. The primary health care provider assigned as the client's medical resident B. The physical therapist who developed the client's exercise program C. The nurse responsible for the client's case management D. The unit-based RN who has cared for the client during the hospital stay

A Prolonged or excessive vomiting results in alkalosis from overelimination of hydrogen ions when stomach hydrochloric acid is lost in the vomit.

Which problem does the nurse expect resulted in a client's acid-base imbalance during an illness that causes vomiting for 2 days? A. Alkalosis from overelimination of hydrogen ions B. Acidosis from overproduction of of hydrogen ions C. Alkalosis from overproduction of bicarbonate ions D. Acidosis from underelimination of bicarbonate ions

Which set of client arterial blood gas (ABG) values indicates to the nurse that some mechanisms are working to partially compensate for an acid-base imbalance? A. pH 7.42; PaO2 92 mm Hg; CO2 41 mm Hg; HCO3− 28 mEq/L (mmol/L) B. pH 7.46; PaO2 98 mm Hg; CO2 38 mm Hg; HCO3− 30 mEq/L (mmol/L) C. pH 7.22; PaO2 60 mm Hg; CO2 80 mm Hg; HCO3− 22 mEq/L (mmol/L) D. pH 7.29; PaO2 78 mm Hg; CO2 82 mm Hg; HCO3− 36 mEq/L (mmol/L)

A Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated.Gaining 2 lb in a week does not indicate effective management for hypokalemia. An inverted T-wave is associated with worsening hypokalemia. The fasting blood glucose level is not related to recovery from hypokalemia.

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? A. Reports having a bowel movement daily. B. ECG shows an inverted T wave. C. Fasting blood glucose level is 106 mg/dL. D. Two lb weight gain during the past week.

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia? A. 72-year-old taking the diuretic spironolactone for control of hypertension B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hour C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

C, D

With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply. A. Client who has been NPO for 36 hours without fluid replacement B. Client receiving a rapid infusion of normal saline C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours E. Client having a sudden and severe asthma attack F. Client with uncontrolled diabetes mellitus

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