HESI fundamental skills

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1 "I don't mind it." 2 "You seem upset." 3 "This is part of my job." 4 "Nurses get used to this."

2 "You seem upset." The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it" or "Nurses get used to this" negates the client's feelings and presents a negative connotation.

A nurse reviews the medical record of a client with ascites. Which client condition may be contributing to the development of ascites? 1 Portal hypotension 2 Kidney malfunction 3 Diminished plasma protein level 4 Decreased production of potassium

3 The liver manufactures albumin, the major plasma protein. A deficiency of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are not the primary source of the pathologic condition. It is the liver's ability to manufacture albumin that maintains the colloid oncotic pressure. Potassium is not produced by the body, nor is its major function the maintenance of fluid balance.

A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse reassesses the client and notices a pulse deficit of 15. What is the client's apical pulse? 1 95 2 85 3 75 4 65

1 95 Dysrhythmias are often associated with pulse deficits. A pulse deficit is the difference between the apical and radial pulse rates. Thus, when the radial pulse (80) and the pulse deficit (15) are added together, the apical pulse would be 95.

How many rights of delegation are there in the nursing practice?

5 There are five rights of delegation in nursing practice. They are right task, right circumstances, right person, right direction/communication, and right supervision/evaluation.

A nurse is assessing four clients. Which client is at the highest medical risk of coronary heart disease and hypertension?

A body mass index (BMI) higher than 30 is considered obesity and puts the client at a higher medical risk of coronary heart disease, some cancers, and hypertension. Client D (who is 145 cm tall and weighs 67 kg) has a BMI of 31.9, which indicates obesity. This can lead to coronary heart disease and hypertension. Client A has a BMI of 21.6, which indicates a normal weight. Client B has a BMI of 27.77, which indicates that the client is overweight but not obese. Client C, with a BMI of 24.24, is considered as having a normal weight.

A client has been placing used insulin needles in a container sealed with heavy-duty tape. The client asks where the container can be disposed of. How should the nurse respond? 1 Take it to the local hazardous waste collection site. 2 Place it in the regular household trash. 3 Take it to the local health department for disposal. 4 Mail it to the Environmental Protection Agency (EPA).

1 Each state (province) has its own waste management guidelines for proper disposal of sharps containers, as well as hazardous waste collection sites. Clients cannot place needles in the regular household trash because sharps are considered medical waste. The local health department does not collect sharps containers. Sharps containers are not mailed directly to the EPA.

Which concept refers to respecting the rights of others? 1 Maturity 2 Systematicity 3 Inquisitiveness 4 Open-mindedness

4 Open-mindedness refers to respecting the rights of others and being tolerant of different viewpoints. Maturity refers to reflecting on one's own judgments and having cognitive maturity. Systematicity refers to being organized and focused. Inquisitiveness refers to acquiring knowledge.

A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse? 1 Nurse practitioner 2 Nurse administrator 3 Certified nurse-midwife 4 Clinical nurse specialist

4 Clinical nurse specialist

A registered nurse is educating a nursing student on the various classifications of torts. What acts are classified as intentional torts in nursing practice? Select all that apply. 1 Battery 2 Assault 3 Negligence 4 Malpractice 5 False Imprisonment

1 Battery 2 Assault 5 False imprisonment Intentional torts include battery, assault, and false imprisonment. Unintentional torts include negligence and malpractice.

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output? Record your answer using a whole number. _____mL/min

5040 The volume of blood pumped by the heart in 1 minute is the cardiac output. Cardiac output is the product of the heart rate and the stroke volume of the ventricle. Therefore cardiac output in the client with a heart rate of 72 beats/min and stroke volume of 70 mL is 5040 mL/min: 72 × 70 = 5040.

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? 1 "I will avoid the pooling of urine in the tubing." 2 "I will avoid prolonged clamping of the tubing." 3 "I will avoid draining urine from the tubing before ambulation." 4 "I will avoid raising the drainage tube above the level of the bladder."

3 Urine should be drained [1] [2] from the tubing into the drainage container before ambulation or exercise. Pooling of the urine in the tubing should be avoided because this action may increase the risk of infection. Prolonged clamping of the tubing should be avoided because intermittent clamping helps to maintain the bladder's capacity and tone. The drainage tube should not be raised above the level of the bladder; urine should flow freely by way of gravity.

An emancipated minor admitted to the healthcare setting states "I have not had proper meals since last week." Which needs should the nurse address using Maslow's hierarchy of needs? 1 Physiological 2 Self-actualization 3 Safety and security 4 Love and belonging needs

1 According to Maslow's hierarchy of needs, the basic human needs are food, water, safety, and love. In the given scenario, the client has not been able to eat since last week so, the nurse should address the physiological need of the client first. Self-actualization deals with the need to achieve one's highest potential. Safety and security includes the physical and psychological safety of the client. Love and belonging needs includes the need to give and receive love and affection.

A nurse is assessing a client who was admitted with a head injury that occurred 4 days ago and is diagnosed with an injury to the speech center in the cerebral cortex. Upon further assessment, the nurse finds that the client is unable to understand written or verbal speech. Which condition does the nurse suspect? 1 Aphasia 2 Dysarthria 3 Borborygmi 4 Tactile fremitus

1 Aphasia of the receptive type is a condition in which the client cannot understand written or verbal speech. This may be due to injury to the cerebral cortex. Dysarthria is a motor speech disorder in which the client has difficulty speaking caused by impairment of the muscles used in speech. Borborygmi are rumbling noises made by the movement of fluid and gas in the intestine. Tactile fremitus is the vibration created during speech by the vocal cords when sound is transmitted through the lung to the chest wall.

A nurse is reviewing a client's serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid? 1 They both contain the same kinds of ions. 2 Plasma exerts lower osmotic pressure than does interstitial fluid. 3 Plasma contains more of each kind of ion than does interstitial fluid. 4 Sodium is higher in plasma, whereas potassium is higher in interstitial fluid.

1 Blood plasma and interstitial fluid are both part of the extracellular fluid and are of the same ionic composition. The osmotic pressure is the same. The composition is the same. The main cation of both extracellular fluids is sodium.

A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes? 1 "A nurse should provide a personal point of view." 2 "Negotiations should be held in formal settings only." 3 "Negotiation takes place immediately after gathering information." 4 "The group agrees to a statement of the problem during the negotiation process."

1 During the process of negotiating outcomes, the nurse is required to provide a personal point of view. Negotiations may take place informally at the client's bedside or in a formal setting. After gathering relevant information regarding an ethical dilemma, the nurse is required to examine his or her own values and formulate an opinion regarding the matter. When verbalizing the problem, the group agrees to a statement of the problem to begin discussions. This step is performed before negotiating outcomes. Negotiations take place after determining all possible courses of action.

Which condition in the client indicates need of nursing care that supports homeostatic regulation? Select all that apply. 1 Damaged tissue 2 Obstructed airway 3 Poor nutritional status 4 Restricted body movement 5 Altered patterns of urinary elimination

1 2 Damaged tissue and an obstructed airway indicate that the client needs nursing care that supports homeostatic regulation [1] [2] Poor nutritional status, restricted body movement, and altered patterns of urinary elimination indicate that the client is in need of care that supports physical functioning.

Which nursing assessment questions assess the faith, belief, fellowship, and community aspect of a client's spirituality? Select all that apply. 1 "What gives meaning to your life?" 2 "What is your source of power, hope, and belief during difficult times?" 3 "In what way do your beliefs help or strengthen you for coping with illness?" 4 "How has the illness affected your capability to express what is essential in life?" 5 "How do you feel the changes caused by the illness are affecting or will affect your life?"

1 2 3 A nurse can assess the faith, belief, fellowship, and community aspect of a client's spirituality by asking a client what gives meaning to his or her life, about his or her source of power, hope, or belief during difficult times, and about how his or her beliefs help or strengthen him or her for coping with illness. When a nurse asks the client in what way illness affects his or her capability to express what is essential in life, it helps in assessing the vocation aspect of spirituality. When a nurse asks the client how he or she feels about the changes that have been caused by the illness, it helps in assessing the life and self-responsibility aspect of spirituality.

A registered nurse is educating a nursing student about the utilitarian system of ethics. What information should the nurse provide? Select all that apply. 1 "The value of something is decided by its usefulness." 2 "The main emphasis is on the outcome or consequence of the action." 3 "The system examines a situation for the presence of essential right or wrong." 4 "The greatest good for the greatest number of people determines the right action." 5 "The actions can be determined whether right or wrong based on their 'right-making characteristics.'"

1 2 4 According to utilitarianism, the value of something is decided by its usefulness. This system is also called consequentialism since the primary emphasis is on the outcome or consequence of the action. According to utilitarianism, the right action is based on the greatest good for the greatest number of people. Deontology examines a situation for the presence of essential right or wrong. According to deontology, actions can be decided as right or wrong based on their "right-making characteristics."

The nurse is caring for a community-dwelling older adult who is suffering from confusion. Which are the best nursing interventions in this situation? Select all that apply. 1 The nurse should provide a protective environment. 2 The nurse should assist with personal hygiene. 3 The nurse should educate the client about correct body mechanics. 4 The nurse should promote activities that reinforce reality. 5 The nurse should teach the client's caregiver proper feeding techniques.

1 2 4 When caring for an older adult who is in a confused state, the nurse should provide a protective environment, assist with personal hygiene, and promote activities that reinforce reality. If a client is suffering from arthritis, the nurse should educate him or her about correct body mechanics. If the nurse is caring for a dementia client, then he or she should teach the family caregiver proper feeding techniques.

What nursing actions best promote communication when obtaining a nursing history? Select all that apply. 1 Establishing eye contact 2 Paraphrasing the client's message 3 Asking "why" and "how" questions 4 Using broad, open-ended statements 5 Reassuring the client that there is no cause for alarm 6 Asking questions that can be answered with a "yes" or "no"

1 2 4 Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not promote communication. Direct questions do not open or promote communication.

An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply. 1 Minimizing medications 2 Modifying the home environment 3 Teaching clients about the safe use of the Internet 4 Manage foot and footwear problems 5 Providing information about the effects of using alcohol

1 2 4 The nursing interventions followed to prevent falls are minimizing medications, modifying the home environment and managing foot and footwear problems. Teaching clients about the safe use of Internet may be an effective intervention for preventing delirium. Providing information about the effects of using alcohol is not an intervention for older adults; this action is more beneficial for adolescents.

While assessing the vital signs of an elderly alcoholic client with symptoms of cardiovascular collapse, the nurse notes that the client's skin is warm. What other findings does the nurse expect to observe? Select all that apply. 1 Body temperature of 84.2 °F 2 Body temperature of 100.6 °F 3 Blood pressure of 100/62 mmHg 4 Respiratory rate of 12 breaths/minute 5 Respiratory rate of 16 breaths/minute

1 3 4 Alcohol acts as a vasodilator in the body; therefore, it causes dilation of surface blood vessels and results in hypothermia due to loss of body heat. However, the skin of the alcoholic client gives a false sensation of warmth, even while the client shows symptoms of hypothermia. Therefore the nurse finds the body temperature of the client is less than 86 °F. Cardiovascular collapse can result in clients with severe hypothermia. During severe hypothermic conditions, the blood pressure of the client decreases. Hypothermia lowers the respiratory rate; therefore, the client may have a respiratory rate of 12 breaths/minute. As the client does not have hyperthermia, he or she does not have a body temperature of 100.6 °F. The normal respiratory rate for elderly clients is in the range of 12 to 18 breaths per minute. Individuals with hypothermia may not have a normal respiratory rate of 16 breaths/minute.

What are the instances when an adult can give consent for medical treatment? Select all that apply. 1 Any guardian for the adult's ward 2 Any parent for the adult's emancipated minor 3 Any parent for the adult's unemancipated minor 4 Any adult for the treatment of his or her minor brother or sister (if an emergency and parents are not present) 5 As a grandparent for a minor grandchild under normal circumstances

1 3 4 An adult can give consent for medical treatment as a guardian for his or her ward. An adult can give consent for medical treatment as a parent for his or her unemancipated minor. An adult can give consent for the medical treatment of his or her brother or sister in case of an emergency if the client's parents are not present. An adult cannot give consent for his or her emancipated minor. An adult can only give consent as a grandparent for a minor grandchild in emergency cases when the parents are not present.

While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse's conclusion? Select all that apply. Correct1 "I have difficulty judging things." 2 "I forget to take medicines." 3 "I am unable to do financial calculations." 4 "I get confused about the proper date and time." 5 "I am unable to recall words during conversations with my family."

1 3 5 Poor judgment, loss of the ability to calculate, and loss of language skills are related to cognitive impairment. These changes may develop due to an imbalance of neurotransmitters in brain. Forgetfulness and getting confused are symptoms that may be associated with normal aging changes.

Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. 1 Encouraging regular dental checkups 2 Facilitating smoking cessation programs 3 Administering influenza vaccines to older adults 4 Teaching the procedure for breast self-examination 5 Referring clients with a chronic illness to a support group

1 4 Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? Select all that apply. 1 Airborne 2 Contact 3 Droplet 4 Hazardous wastes 5 Standard

1 Airborne 2 Contact 5 Standard Airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Varicella can be transmitted by airborne and contact routes. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods. Nurses should treat all body excretions, secretions, and moist membranes/tissues, excluding perspiration, as potentially infectious and thus as hazardous wastes. Contact and airborne precautions must be used. Standard precautions are used with every client.

A client calls out to all nursing staff members who pass by the door and asks them to do or get something. How can the nurse best manage this problem while meeting this client's needs? 1 Assign one staff member to approach the client regularly and interact with the client. 2 Close the door to the room so that the client cannot see the staff members as they pass by. 3 Inform the client that one staff member will come in frequently and check whether the client has any requests. 4 Arrange for a variety of staff members to take turns going into the room to see whether the client has any requests.

1 Assign one staff member to approach the client regularly and interact with the client. Assigning one staff member to approach and interact with the client regularly provides continuity and demonstrates to the client that the nursing staff is concerned; frequent contact should also reduce the client's need to call the staff for reassurance. Closing the door to the room so that the client cannot see the staff members as they pass by may increase the client's anxiety and the need for contact with staff. Telling the client that staff will come frequently is not the same as doing it; the client may not believe it which can also increase anxiety. Arranging for a variety of staff members to take turns going into the room to see whether the client has any requests will not facilitate the development of a therapeutic relationship with a staff member.

A nurse questions the staff about a change in a client's plan of care. What does this demonstrate? 1 Authority 2 Autonomy 3 Responsibility 4 Accountability

1 Authority The nurse asking questions about a change in a client's plan of care shows that the nurse has the power to make decisions. This is an example of the nurse's authority over other staff members. Independence in making choices about client care and work is autonomy. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability means that individuals are answerable for their actions. The nurse demonstrates accountability by checking on the client and family after discharge.

A nurse should employ which technique to maintain surgical asepsis? 1 Change the sterile field after sterile water is spilled on it. 2 Put on sterile gloves and then open a container of sterile saline. 3 Place a sterile dressing no more than half an inch from the edge of the sterile field. 4 Clean the surgical area with a circular motion, moving from the outer edge toward the center.

1 Change the sterile field after sterile water is spilled on it.

When trying to promote effective learning in a client with a newly diagnosed disease, what should the nurse consider? 1 Client's past experiences 2 Client's personal resources 3 Stress of the total situation

1 Client's past experiences Past experiences have the most meaningful influence on present learning. Although the client's personal resources, the stress of the total situation, and the type of onset of the disease affect learning, their influence is not as great as past experiences.

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the hand is used to perform this assessment? 1 Fingertips 2 Pads of fingertips 3 Ulnar surface of hand 4 Palmer surface of finger pads

1 Fingertips The fingertips are used to palpate the skin for elasticity. The pads of the fingertips are used to palpate pulse amplitude. The ulnar surface of the hand is used to detect fremitus. The palmer surface of the fingertips is used to examine the thorax.

A registered nurse is teaching a nursing student about Nightingale's theory of nursing. Which statements have been correctly stated by the nursing student as a result of the teaching? Select all that apply. 1 Nightingale's theory states that the focus of nursing is caring through the environment. 2 Nightingale's theory limits nursing to the administration of medications and treatment. 3 Nightingale's theory suggests that every nurse should know all about the disease process. 4 Nightingale's theory is oriented towards providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. 5 Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness.

1 Nightingale's theory states that the focus of nursing is caring through the environment. 3 Nightingale's theory suggests that every nurse should know all about the disease process. 5 Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness. Florence Nightingale's theory of nursing focuses on nursing by caring through the environment. Nightingale's theory is oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness. Nightingale's theory does not limit nursing to the administration of medications and treatment. Nightingale's theory suggests that nurses do not need to know all about the disease process, which differentiates nursing from medicine

A nurse is recalling the various levels of preventive care to promote health, wellness, and to prevent illness. Which scenario is a perfect example of primary prevention? 1 An infant receives rotavirus vaccination in the hospital setting. 2 An adult in the early stages of Parkinson's disease is advised to perform adequate exercise. 3 An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. 4 An older adult with Parkinson's disease is administered carbidopa-levodopa to slow the progression of the disease.

1 Primary prevention consists of all health promotion efforts and wellness education activities. An infant receiving the rotavirus vaccination is an example of primary prevention. An adult in the early stages of Parkinson's disease is advised to perform adequate exercises; this is an example of secondary prevention. An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. This is an example of tertiary prevention. An older adult with Parkinson's disease is administered carbidopa-levodopa to slow the progression of the disease. This is an example of secondary prevention.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply. 1 Respiratory rate of 14 breaths/minute 2 Blood pressure of 120/80 mmHg 3 Oxygen saturation of 95% 4 Temporal temperature of 37.4 °C 5 Radial pulse rate of 72 and irregular

1 Respiratory rate of 14 breaths/minute 2 Blood pressure of 120/80 mmHg 3 Oxygen saturation of 95% In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings. Therefore, the registered nurse should reassess these vital signs. The normal temperature range is 36 to 38 0C; this range is unaffected by a pulmonary infection. Therefore, the nurse does not need to reassess the temperature. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular. Therefore reassessment would not be required.

A client tells the nurse, "I keep reverting to my old habit of drinking soda, although I have stopped drinking as much." What stage of health behavior change has the client reached? 1 Action stage 2 Preparation stage 3 Maintenance stage 4 Contemplation stage

1 The client in this situation has reached the action stage of health behavior change. In this stage, old habits may get in the way of new behaviors. In the preparation stage, the client understands that the advantages of the health behavior change outweigh its disadvantages. In this situation, the client has already made changes in health behavior. In the maintenance stage, the client continues the health behavior change indefinitely. In the contemplation stage, the client may be ambivalent but is more ready to accept information regarding health behavior change.

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1 Whether the client is allowed to give consent 2 That the client cannot make informed decisions about healthcare 3 Whether the client is permitted to give voluntary consent when parents are not available 4 That the client probably will be unable to choose between alternatives when asked to consent

1 Whether the client is allowed to give consent A person is legally unable to sign a consent until the age of 18 or 19 years (depending upon individual state or provincial laws) unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches (5 to 7.5 cm). 4 Clamp the tube for 2 minutes and then restart the infusion.

2 Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

A nurse teaches a client about various measures to protect against food-borne illness. Which statement by the client indicates a need for further teaching? 1 "I'll clean the inside of my refrigerator and microwave regularly." 2 "I'll wash my cooking utensils and cutting boards with tap water." 3 "I'll wash my hands with warm, soapy water before touching or eating food." Incorrect4 "I won't eat any leftovers in my refrigerator after they've been there for 5 days."

2 Eating leftovers that have been kept in a refrigerator for more than 2 days may result in a food-borne illness caused by microbial growth in the food. Cleaning the inside of the refrigerator and microwave regularly will help prevent microbial growth. Cooking utensils and cutting boards should be washed with hot, soapy tap water as a means of preventing food-borne illness. Washing the hands with warm, soapy water before touching or eating food is one technique for preventing food borne illness.

Which infant is likely to need iron supplementation throughout the first year? 1 A full-term infant who is breast feeding. 2 A full-term infant who is receiving formula. 3 A breastfed infant who is four months old. 4 A breastfed infant who is six months old.

2 Formula is fortified with iron; however, this iron is less readily absorbed than the iron in breast milk. Therefore, a full-term infant who is given formula must receive iron-fortified formula throughout the first year. If the infant is breast feeding, there is no need for iron supplements. A breastfed infant absorbs adequate iron from breast milk during the first four to six months of life.

A nurse administers medication via the central venous access device (CVAD) and forgets to monitor the client at the required intervals. The client then develops phlebitis. What charges may the nurse face for this action? 1 Battery 2 Malpractice 3 False Imprisonment 4 Defamation of Character

2 The nurse may face malpractice charges due to the failure to monitor the client in a timely manner after administering medications through a central venous access device (CVAD). Battery is any intentional touching without the client's consent. False Imprisonment is an intentional tort that occurs when a client is placed under restraints without legal documentation. Defamation of character is the publication of false statements that result in damage to a person's reputation.

What is the role of a nurse administrator in a healthcare setting? 1 Providing surgical anesthesia under the guidance and supervision of an anesthesiologist 2 Preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development 3 Providing comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions 4 Providing knowledge about current nursing practices, trends, theories, and necessary skills in laboratories and clinical settings

2 A nurse administrator's function is to prepare the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development. A certified registered nurse anesthetist provides surgical anesthesia under the guidance and supervision of an anesthesiologist. The nurse practitioner provides comprehensive care and directly manages the medical care of clients who are healthy or have chronic conditions. Nurse educators provide knowledge about current nursing practices, trends, theories, and necessary skills in laboratories and clinical settings.

Which role does a nurse play when helping clients to identify and clarify health problems and to choose appropriate courses of action to solve those problems? 1 Educator 2 Counselor 3 Change agent 4 Case manager

2 As a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. As an educator, the nurse teaches clients and their families to assume responsibility for their own health care. A nurse acts as a change agent within a family system or as a mediator for problems within a client's community; this involves identifying and implementing new and more effective approaches to problems. As a case manager, the nurse establishes an appropriate plan of care on the basis of assessment findings and coordinates needed resources and services for the client's well-being along a continuum of care. Test-Taking Tip: Reread the q

During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? 1 Spiritual belief 2 Family practices 3 Emotional factors 4 Cultural background

2 Family practices influence the client's perception of the seriousness of diseases. The client does not feel the need to seek preventive care measures because no family member practices preventive care. The client is not influenced by spiritual beliefs in this instance. An individual's spiritual beliefs and religious practices may restrict the use of certain forms of medical treatment. Emotional factors such as stress, depression, or fear may influence an individual's health practice; however, this client does not show signs of being affected by emotional factors. The client is said to be influenced by cultural background if he or she follows certain beliefs about the causes of illness and uses customary practices to restore health.

Which nursing diagnosis is an example of a client response to a health condition? 1 Risk for acute confusion 2 Impaired social interaction 3 Readiness for enhanced nutrition 4 Readiness for increased family coping

2 Impaired social interaction is an example of a client response to a health condition. Any nursing diagnoses beginning with "risk for" describes human responses to conditions that have not yet occurred, such as Risk for acute confusion. A health promotion nursing diagnosis reflects the clinical judgment that the individual or family client is willing to act to improve their health to prevent the onset of a health condition which has not yet occurred. Readiness for enhanced nutrition and readiness for enhanced family coping are examples of health promotion nursing diagnoses.

The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." What does the nurse determine that the client needs to be taught about? 1 Need for home-delivered meals 2 Foods that meet basic nutritional needs 3 Effect of aging on the need for some foods 4 Need for meat at least once per day throughout life

2 The need for nutrients, including protein, that meet basic nutritional needs continues throughout life. The priority is to educate the client, although home-delivered meals may be one way to provide adequate nutrition. Aging has no effect on the specific nutrients needed; however, it may influence digestion or absorption of food. Protein is needed every day, but it does not have to be in the form of meat.

A nurse educates a client about the role played by an individual in taking responsibility for health and wellness and its impact. What instructions should the nurse give? Select all that apply. 1 "An individual should use passive strategies for health promotion." 2 "An individual should know that lifestyle choices affect his or her quality of life and well-being." 3 "An individual should take responsibility of health and wellness by making proper lifestyle choices." 4 "An individual should realize that illness prevention has a positive economic impact on his or her life." 5 "An individual should understand that it is enough to make positive lifestyle choices in order to prevent illness."

2 3 4 A client should understand that making appropriate lifestyle choices can affect his or her quality of life and well-being. An individual should take responsibility for his or her health and wellness by making proper lifestyle choices. The client should also realize that illness prevention has a positive economic impact by decreasing health care costs. Passive health promotion strategies enable people to benefit from the activities of others. These strategies do not require the involvement of the clients. The client should understand that making positive lifestyle choices and discarding negative lifestyle choices contribute to illness prevention.

The nurse listens to and validates the feelings expressed by a confused older adult. Which elements does the nurse convey in this situation? Select all that apply. 1 Recalling 2 Respecting 3 Reassuring 4 Reinforcing 5 Understanding

2 3 5 Validation therapy is an alternative approach to communication with a confused older adult. By listening with sensitivity to the client and validating what the client is expressing, the nurse conveys respect, reassurance, and understanding. Recalling is related to reminiscence. Reinforcing is not related to validation.

The nurse reviews the medical record of a client who is eligible to receive end-of-life care. What are the criteria for a client to receive this type of care? Select all that apply. 1 When the client is nearing death 2 When the expected death of the client is within 6 months 3 When the client seeks no aggressive disease management 4 When a family member has signed an informed consent form 5 When the client has been issued a "do not resuscitate" order

2 3 5 Clients who do not seek aggressive disease management and are expected to die in a span of 6 months are eligible for end-of-life care. The client may require end-of-life care when he or she has signed a "do not resuscitate" order. A client who is nearing death may not receive end-of-life care; instead, the client receives comfort care. An informed consent form signed by a family member is not necessary for the client to receive end-of-life care.

A registered nurse is educating a nursing student about the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Which points mentioned by the nursing student post-teaching are correct? Select all that apply. 1 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are not affected by nursing environments. 2 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey developed to measure client perceptions of their hospital experience. 3 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is administered to a randomly selected sample of adults who were discharged from a hospital between 48 hours and 6 weeks ago. 4 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) was developed by the National Committee for Quality Assurance (NCQA) as a way for hospitals to collect and report data publicly for comparison purposes. 5 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys have 27 questions that ask clients to rate their communication with nurses and physicians, discuss other details about treatment, and share their willingness to recommend the hospital.

2 3 5 The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey developed to measure client perceptions of their hospital experience. The survey is administered to a randomly selected sample of adults who were discharged from a hospital between 48 hours and 6 weeks ago. The survey has 27 questions that ask clients to rate their communication with nurses and physicians, discuss other details about treatment, and share their willingness to recommend the hospital. HCAHPS scores are affected by nursing environments. HCAHPS was developed by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality to enable hospitals to collect and report data publicly for comparison purposes. The National Committee for Quality Assurance (NCQA) created Healthcare Effectiveness Data and Information Set (HEDIS) to collect various data to measure the quality of care and services provided by different health plans.

Which is used for determining the hours of care and staff required for a group of clients? 1 Flow sheets 2 Acuity records 3 Standardized care plans 4 Discharge summary forms

2 An acuity record is used to determine the hours of care and staff required for a given group of clients. A client's acuity level is based on the type and number of nursing interventions. Accurate acuity ratings justify overtime and the number and qualifications of staff needed to safely care for clients. A flow sheet helps to assess data about a client; this data includes vital signs and routine repetitive care. Standardized care plans based on an institution's standards of nursing practice are preprinted and established guidelines used to care for clients who have similar health problems. Discharge documentation includes medications, diet, community resources, follow-up care, and medical contact information in case of an emergency or query.

In which role does the nurse oversee the budget of a specific nursing unit or agency? 1 Nurse educator 2 Nurse manager 3 Nurse researcher 4 Nurse practitioner

2 Nurse manager

While entering data for a client in the electronic health record (EHR), the nurse uses North American Nursing Diagnosis Association (NANDA) International terminology to document which part of the nursing process? 1 Planning 2 Diagnosis 3 Outcomes 4 Interventions

2 The NANDA International terminology provides code numbers for the diagnosis of various diseases. Therefore the nurse would use NANDA International for entering the client's diagnosis. The NANDA International terminology does not give codes for planning, outcomes, and interventions. The nurse would document planning under the planning portion of the electronic health record. The nurse would use nursing interventions classification for entering interventions in the client's EHR. The nurse would use nursing outcomes classification for documenting the outcomes of the treatment in the EHR.

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child? 1 Avoid answering questions. 2 Give the child a list of expectations. 3 Be consistent about established rules. 4 Allow the child to plan the day's activities.

3 Because of a short attention span and distractibility, consistent limit setting is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts. Questions should be answered, but the answers should not be judgmental. A list of expectations may be overwhelming at this age. Parents need to assist children with routine tasks; children this age may not be concerned with time frames.

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? 1 Dry mouth 2 Skin reactions 3 Mucosal edema 4 Bone marrow suppression

3 The mucosal lining of the oral cavity, oropharynx, and esophagus is sensitive to the effects of radiation therapy; the inflammatory response causes mucosal edema that may progress to an airway obstruction. A decrease in salivary secretions resulting in dry mouth may interfere with nutritional intake, but it is not life threatening. Erythema of the skin may cause dry or wet desquamation, but it is not life threatening. Radiation to the neck area should not produce as significant bone marrow suppression as radiation to the other sites.

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings? 1 Syphilis 2 Iron deficiency anemia 3 Subacute bacterial endocarditis 4 Chronic obstructive pulmonary disease

3 Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute bacterial endocarditis, or trichinosis and are called splinter hemorrhages. Conditions such as syphilis and iron deficiency anemia cause concavely curved nails, called koilonychia. Heart and lung abnormalities such as chronic obstructive pulmonary disease cause clubbing of the nail beds.

A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates? 1 A depressed immune system 2 An active tuberculosis infection 3 A previous exposure to the organism 4 An imminent tuberculosis infection

3 The presence of antibodies indicates past exposure to or infection with an organism that may be presently dormant. A positive response does not indicate the status of the immune system. A positive response does not necessarily indicate active TB infection; a purified protein derivative (PPD) test administered to an individual with active TB may cause a severe reaction. A positive PPD test does not predict forthcoming exposure or infection; it only indicates past exposure to the organism.

When assessing a client who is receiving palliative care, which question regarding spiritual health is most appropriate? 1 "Are you afraid of death?" 2 "After hearing about your condition, didn't you lose faith?" 3 "What is your source of spiritual strength during hard times?" 4 "Let me ask the chaplain to visit you in order to help you cope. "

3 When assessing a client who is receiving palliative care, it is appropriate for the nurse to ask about the client's source of spiritual strength during hard times. This helps the nurse understands the client's spiritual practices, facilitating quality care. The nurse should not ask the client if he or she is afraid of death because this is not supportive. Assuming a client has lost his or her faith upon diagnosis is inappropriate and unsupportive. Because not all clients identify with a religion, it is not appropriate to call the hospital chaplain unless the client requests this.

Which client body temperatures are indicative of moderate hypothermia? Select all that apply. 1 80° F (26.7° C) 2 84° F (28.9° C) 3 88° F (31.1° C) 4 92° F (33.3° C) 5 96° F (35.6° C)

3 4 Moderate hypothermia is a body temperature between 86°F and 93.2°F (30° C to 34° C). Therefore clients with body temperatures between 88°F and 92°F (31.1° C to 33.3° C) have moderate hypothermia. Mild hypothermia is a body temperature between 93.2°F and 96.8°F (34° C to 36° C). Therefore clients with body temperatures of 96°F (35.6° C) have mild hypothermia. Body temperature below 86°F (30° C) indicates severe hypothermia.

The nurse is collecting case reports that can be analyzed using the failure mode effective analysis (FMEA) tool. Which case files should the nurse collect? Select all that apply. 1 A client is in a coma due to severe hemolytic transfusion reaction. 2 A client with depression committed suicide by falling off the terrace of the hospital. 3 A client had a retained foreign body left during surgery which was removed immediately. 4 A client who was in wheelchair was rescued from falling in the corridor of the hospital. 5 A client developed a urinary tract infection after 4 days of continuous catheterization.

3 4 5 The failure mode effective analysis tool is used to analyze the cause of near-miss events and adverse events. A retained foreign body after surgery if removed immediately is a type of near-miss event. A client developing a urinary tract infection after catheterization is a type of adverse event. A wheelchair-bound client was rescued from falling in the hospital corridor is a type of near-miss event. The cause of these events can be analyzed using the FMEA tool. A client in a coma due to severe hemolytic transfusion reaction and a depressed client who committed suicide are types of sentinel events. The cause of these events can be assessed by using the root cause analysis tool.

According to Sigmund Freud's developmental theory, which developmental age is called the latent stage? 1 Toddler 2 Preschool 3 Middle childhood 4 Adolescence

3 According to Sigmund Freud's developmental theory, middle childhood age is the latent stage. Early childhood and toddlers are in the anal stage. Preschool is the phallic stage. Adolescence is the genital stage.

A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake? 1 Diagnosis 2 Evaluation 3 Assessment 4 Implementation

3 Assessment The documentation of the client's information is part of an assessment. The nurse will collect all the relevant medical data of the client to help the doctor understand the client's history a make an accurate diagnosis. During diagnosis, the collected data is analyzed to find out the client's problems or issues. Evaluation is the process to see if the expected outcomes of the treatment are achieved or not. Before an evaluation, a plan is made to solve all the client's problems and then the plan is implemented.

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. 2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. 3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities after hospitalization do not require rehabilitation.

3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to prevent complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the primary healthcare provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.

A client is in a state of ambivalence. Which of these stages of health behavior will the nurse suspect? 1 Preparation 2 Maintenance 3 Contemplation 4 Precontemplation

3 Contemplation The nurse will suspect the stage of contemplation. This stage of health behavior is characterized by a client's attitude towards a change; the client is most likely to accept that change in the next six months. The stage of preparation is when a client believes that a change in his or her behavior is advantageous. During the maintenance stage, changes need to be implemented in the client's lifestyle. In the precontemplation stage, the client is not willing to hear any information about the changes in the behavior.

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound? 1 Inflammation of the pleura 2 Muscular spasms in the larger airways 3 Sudden reinflation of groups of alveoli 4 High velocity airflow through an obstructed airway

4 High velocity airflow through an obstructed airway

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? 1 Asking about what type of foods the client usually eats 2 Telling the client that the diet must be followed exactly as written 3 Telling the client that the intake of foods on the list must be limited 4 Asking about what the client knows about the diet that was prescribed

4 Asking about what the client knows about the prescribed diet may validate the client's understanding; the response may indicate the need for further teaching or that the client understands; understanding and accepting the need for restrictions will increase adherence to the diet. Assessing the client's food preferences and teaching about diets follow an assessment of the client's understanding about the need for a specific diet; the client must understand the need for and the benefits of the diet before there is a readiness for learning. Telling the client that the diet must be followed exactly as written and telling the client that the intake of foods on the list must be limited are authoritarian and should be avoided.

What does a nurse understand by the quality improvement competency, according to Quality and Safety Education (QSEN)? 1 Using information and technology to communicate, manage knowledge, mitigate errors, and support decision-making 2 Integrating best current evidence with clinical expertise along with client and family preferences and values for the delivery of quality healthcare 3 Functioning effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision making to achieve quality client care 4 Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems

4 The quality improvement competency states that a nurse should use data to monitor the outcomes of healthcare processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems. According to the competency called informatics, a nurse should use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. As per the competency called evidence-based practice, a nurse should integrate best current evidence with clinical expertise and client and family preferences and values for the delivery of quality healthcare. According to the competency called teamwork and collaboration, a nurse should function effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision making to achieve quality client care.

A registered nurse notices that a student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. What is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg? 1 130/80 mm Hg 2 150/100 mm Hg 3 140/100 mm Hg 4 130/100 mm Hg

4 130/100 mm Hg Deflating the cuff too quickly will result in false low systolic and false high diastolic readings. Therefore the client's systolic readings decreased to 130 mm Hg while the diastolic readings increased to 100 mm Hg. If the bladder or cuff is too wide, it results in false low readings in the client, as in the blood pressure of 130/80 mm Hg. If the bladder or cuff is too narrow or too short or if the cuff is wrapped too loosely or unevenly, the result is a false high, as in the blood pressure of 150/100 mm Hg. Deflating the cuff too slowly results in false high diastolic readings, such as the blood pressure of 140/100 mm Hg.

Which opposing conflict would a middle-aged adult face according to Erikson's theory of psychosocial development? 1 Integrity versus Despair 2 Intimacy versus Isolation 3 Identity versus Role Confusion 4 Generativity versus Self-Absorption and Stagnation

4 According to Erikson's theory of psychosocial development, a middle-aged adult is likely to face the opposing conflicts Generativity versus Self-Absorption and Stagnation. An older adult is likely to face the opposing conflicts Integrity versus Despair. A young adult may face the opposing conflicts Intimacy versus Isolation. An adolescent may face the opposing conflicts Identity versus Role Confusion.

How does a nurse prepare a "factual" record when performing a client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each activity of the client 3 By providing complete and appropriate information in each client record 4 By recording descriptive and objective information of what the nurse sees, hears, feels, and smells

4 By recording descriptive and objective information of what the nurse sees, hears, feels, and smells A factual record contains descriptive and objective information about what a nurse sees, hears, feels, and smells. An organized record communicates the information in a logical order. The use of exact measurements establishes accuracy. The nurse prepares a complete record by providing a complete and appropriate record that includes all essential information.

The registered nurse (RN) asks the nursing student about theories related to the aging process. Which statement made by the nursing student indicates the theory of continuity? 1 "The aging process in individuals is genetically programmed." 2 "Aging individuals withdraw from customary roles." 3 "The accumulated damage of the aging process leads to physical changes in individuals." 4 "The personality of an individual remains stable and behavior becomes predictable as they age."

4 Continuity theory suggests that the personality remains stable in an individual while behavior becomes more predictable as people age. This factor ultimately determines the degree of engagement and activity in older adulthood. Nonstochastic theory states that the results of the aging process are controlled by genetically programmed physiological mechanisms. Stochastic theory states that aging is a result of random cellular damage which gradually occurs over time. According to the disengagement theory, aging individuals withdraw themselves from customary roles and engage in self-focused activities.

What type of research explores the interrelationship among variables of interest without any active intervention by a researcher? 1 Historical research 2 Evaluation research 3 Exploratory research 4 Correlation research

4 Correlation research Correlation research involves the exploration of the interrelationship among variables of interest without any active intervention by a researcher. Historical studies are designed to establish facts and relationships concerning past events. Evaluation research tests how well a program, practice, or policy is working. Exploratory research is an initial study designed to develop or refine the dimensions of phenomena.

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set how often? 1 Every 4 to 8 hours 2 Every 12 to 24 hours 3 Every 24 to 48 hours 4 Every 72 to 96 hours

4 Every 72 to 96 hours Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in clients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.

Which statement about Orem's theory needs to be corrected? 1 It determines self-care needs. 2 It explains the types of nursing care. 3 It aids in the design of nursing interventions. 4 It describes factors supporting the health of the family.

4 It describes factors supporting the health of the family Orem's theory explains the factors within a client's living situation. These factors may support or interfere with the client's self-care abilities, but they do not refer to the family's health. This theory interprets data that determine a client's self-care needs, self-care deficits, and self-care abilities. Orem's theory explains, predicts, or describes nursing care that will help the client in bettering his or her health. The theory also aids in the design of nursing interventions for the promotion of self-care by the client during times of illness, such as asthma, diabetes mellitus, or arthritis.

A client who underwent thyroid surgery is unable to speak and communicate. The nurse initially uses closed-ended questions to assess the client's needs. Once the client is stable, the nurse provides a small white board for the client to write and communicate to others. Which critical thinking attitude has the nurse demonstrated? 1 Humility 2 Discipline 3 Risk taking 4 Perseverance

4 Perseverance is finding effective solutions to problems by trying various approaches. A critical thinker would demonstrate perseverance by not becoming satisfied with the solution unless the solution is near perfect. Humility is accepting one's limitations. Discipline is effective management of time and resources. Risk taking is pushing oneself beyond the limits to find solutions to the problem.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? 1 Acknowledge the client's crying. 2 Encourage unrestricted family visits. 3 Explain details of the care being given. 4 Stay nearby without initiating conversation.

4 Stay nearby without initiating conversation. The nurse's presence communicates concern and provides an opportunity for the client to initiate communication; silence is an effective interpersonal technique that permits the client to direct the content and extent of verbalizations without the nurse imposing on the client's privacy. Crying, part of depression, usually ceases when the individual reaches acceptance. During acceptance the client may decide not to have visitors, preferring time for reflection. Detached from the environment, the client may find that the details of various procedures lose significance.

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? 1 Airway obstruction 2 Inadequate nutrition 3 Prolonged gastric suction 4 Excessive mechanical ventilation

4 The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next? 1 Diagnosis 2 Evaluation 3 Assessment 4 Implementation

4 The nurse will administer the tetanus as per the doctor's regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.

A registered nurse is explaining the term "just culture" to the student nurse. Which explanation provided by the registered nurse is accurate? 1 "It refers to the agreement to keep promises." 2 "It refers to taking positive actions to help others." 3 "It refers to the ability to answer for one's actions." 4 "It refers to promoting open discussion whenever error occurs without fear of recrimination."

4 The term "just culture" refers to the promotion of open discussion whenever errors occur without fear of recrimination. Fidelity refers to the agreement to keep promises. Beneficence refers to taking positive actions to help others. Accountability refers to the ability to answer for one's actions.

Why should organizations promote transparency in health care? 1 Transparency helps in creating effective insurance policies. 2 Transparency helps determine whether drugs are being diverted. 3 Transparency facilitates recruitment of competent team members. 4 Transparency allows continuous feedback for improving client outcomes.

4 Transparency allows continuous feedback for improving client outcomes. Transparency means to be clear and unambiguous in the daily operations of a health care organization. Transparency allows continuous feedback for the consumers, which helps improve the clinical outcomes of the clients. Transparency is not related to the diversion of drugs for non-therapeutic purpose. Transparency may not contribute to better recruitment in the organization. Transparency in a health care organization is unrelated to insurance policies.

The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output? Record your answer using a whole number.

495ml Intake: Gastric tube: 250 x 3 = 750 mL; IV: 900 - 550 = 350 mL; Intake total: 1100 mL. Output: Urinary output: 150 + 220 + 235 = 605 mL. I & O difference: 1100 - 605 = 495 mL

Which action should the nurse take to decrease abdominal distention following a client's surgery? 1 Encourage ambulation. 2 Give sips of ginger ale. 3 Provide a straw for drinking. 4 Offer an opioid analgesic.

1 Ambulation will stimulate peristalsis, which increases passage of flatus and decreases abdominal distention. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.

What are the elements of discovery of a lawsuit? Select all that apply. 1 Experts 2 Medical records 3 Proof of negligence 4 The depositions of witnesses 5 Petition-elements of the claim

1 2 4 Experts, medical records, and the depositions of witnesses are elements of discovery of a lawsuit. Proof of negligence is a part of a trial. Petition and elements of the claim are a part of the pleadings phase.

A nurse is recalling common terms that are used in health ethics. What does beneficence in health ethics refer to? 1 Beneficence refers to the agreement to keep promises. 2 Beneficence refers to taking positive actions to help others. 3 Beneficence refers to the ability to answer for one's actions. 4 Beneficence refers to avoiding harming or hurting an individual.

2 Beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Accountability refers to the ability to answer for one's actions. Nonmaleficence refers to avoiding harming an individual.

Which ethical principles govern a nurse's behavior when making difficult decisions about a client's care at the point of care? 1 Bioethics 2 Metaethics 3 Clinical ethics 4 Research ethics

3 Clinical ethics help in decision-making in issues that involve bedside client care and other client-related issues. The principles of bioethics govern ethical issues in biological sciences and technology. Metaethics is a branch of philosophy that deals with fundamental questions about concepts. Research ethics are applicable toward research subjects, whether human or animal.

Which statement defines "information" gathered by the nurse? 1 It is an individual piece of reality. 2 It is a combination of pieces of reality. 3 It is the organization and interpretation of data. 4 It is the identification of relationship of various data.

3 It is the organization and interpretation of data. Information is defined as the organization and interpretation of data or pieces of reality. Datum is an individual piece of reality. When data are combined and relationships among data are identified, the nurse obtains knowledge.

A visitor comes to the nursing station and tells the nurse that a client and a relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? 1 Ask the client if he or she is okay. 2 Call security from the room. 3 Find out if there is anyone else in the room. 4 Ask security to make sure the room is safe.

4 Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and ensured that any other people in the room are safe.

While assessing a client's hair, a nurse notices that the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which statements made by the client indicates an understanding of the teaching? Select all that apply. 1 "I will clean my comb in ammonia water." 2 "I should use lindane-containing shampoo." 3 "I should shampoo my hair in a tub or shower." 4 "I should use a dilute vinegar solution to loosen the nits." 5 "I should use a shampoo treatment once every 24 hours."

1 2 4 5 Lindane may be used to treat lice and scabies, but it may cause serious side effects. Clients with lice are instructed not to wash their hair in a tub or shower because this action may cause the lice to migrate to other sites. Ammonia water should be used to clean combs and other hair accessories to enhance lice control. Nits are loosened by the use of dilute vinegar solution. Shampooing should be continued once every 24 to 48 hours.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 Guided imagery

1 2 4 5 Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

What are the levels of critical thinking in nursing? Select all that apply. 1 Basic 2 Analyze 3 Evaluate 4 Complex 5 Commitment

1 4 5 The three levels of critical thinking in nursing are basic, complex, and commitment. Analyzing and evaluating are skills associated with critical thinking.

A nurse is recalling Piaget's theory of cognitive development. Which statement is a characteristic of the concrete operations stage? 1 "A child is able describe a process without actually doing it." 2 "A child faces difficulty in conceptualizing time." 3 "A child believes that everyone experiences the world exactly as they do." 4 "A child believes that his or her actions and appearance are constantly being scrutinized."

1 A child is able describe a process without actually doing it." In the concrete operations stage, a child is able to perform mental operations and describe a process without actually doing it. In the preoperational stage, a child faces difficulty in conceptualizing time, and he or she believes that everyone experiences the world exactly as they do. In the formal operations stage, an individual believes that his or her actions and appearances are scrutinized constantly.

What is a stressor? 1 A stressor is any stimuli that can produce tension and cause instability within the system. 2 A stressor exists within the client system, such as the physiological and behavioral responses to illnesses. 3 A stressor exists outside the client system; external stressors include changes in healthcare policies or increased the crime rates. 4 A stressor is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

1 A stressor is any stimuli that can produce tension and cause instability within the system. stressor is any stimuli that can produce tension and cause instability within the system. Internal factors exist within the client system, like the physiological and behavioral responses to illnesses. External factors exist outside the client system; these stressors include changes in healthcare policies or increased crime rates. A phenomenon is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations.

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain what? 1 Abduction 2 Adduction 3 Traction 4 Elevation

1 Adduction Abduction means to move the limb away from the median plane, or axis, of the body. In care of the client with a fractured hip, the legs and hip must be aligned in an abducted position to prevent internal rotation, reduce the risk of dislocation, and decrease pain. In a client with a fractured hip, adduction of the limb, traction, and elevation are not appropriate procedures. Adduction means to move the limbs toward the medial plane, or axis, of the body, and traction involves the process of applying a pulling force in opposite directions using weights.

Arrange the order of steps involved in the evidence-based practice process.

1 Ask a clinical question. 2. Collect the most relevant and best evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5 Evaluate the practice decision or change. 6. Share the outcomes of evidence-based practice.

Which antipyretic medication may cause Reye syndrome in children? 1 Aspirin (Anacin) 2 Naproxen (Aleve) 3 Ibuprofen (Advil) 4 Dantrolene (Dantrium)

1 Aspirin Aspirin (Anacin) increases the risk of swelling in the brain and liver, which are the main symptoms of Reye syndrome in children. Therefore aspirin is not recommended in children. Drugs such as naproxen (Aleve) and ibuprofen (Advil) do not induce swelling in the brain and liver; therefore, these drugs may not cause Reye syndrome. Dantrolene (Dantrium) does not induce swelling in the brain and liver; instead, it decreases calcium levels during malignant hyperthermia conditions.

A client with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The registered nurse identifies that which items on the client's care plan are appropriate for a licensed practical nurse (LPN) to perform? Select all that apply. 1 Help the client ambulate when required. 2 Monitor the client's vitals every 30 minutes. 3 Administer adequate oral fluids to the client. 4 Prepare the nursing diagnosis after assessing the client. 5 Administer the digoxin (Cardoxin) if the client has chest pain.

1 Help the client ambulate when required. 2 Monitor the client's vitals every 30 minutes. 3 Administer adequate oral fluids to the client. To provide safe care, the nurse should act within the scope of practice and certification. The licensed practice nurse (LPN) can monitor the vitals, ambulate the client, and administer oral fluids to prevent dehydration. The LPN cannot administer medications intravenously and cannot formulate nursing diagnosis; therefore, these two actions do not fall within the scope of the LPN's practice.

A nursing student is listing the different aspects of the healthcare services pyramid. Under which type of healthcare services should the nursing student include family planning? 1 Primary care 2 Continuing care 3 Restorative care 4 Secondary Acute care

1 The nursing student should include family planning under primary care. Family planning is not a part of continuing care, restorative care or secondary acute care healthcare services.

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be? 1 29° C 2 33° C 3 36° C 4 38° C

2 A body temperature in the range of 36° to 38° C is normal. When skin temperature drops below 35° C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30° C represents severe hyperthermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33° C.

An older adult is found to have a thin white ring around the margin of the iris. What condition does this denote? 1 Cataract 2 Arcus senilis 3 Conjunctivitis 4 Macular degeneration

2 In older adults, the iris becomes faded and a thin white ring (known as arcus senilis) appears around the margin of the iris. A cataract is a condition involving increased opacity of the lens that blocks light rays from entering the eye. The presence of redness indicates allergic or infectious conjunctivitis. Macular degeneration is marked by a blurring of central vision caused by progressive degeneration of the center of the retina.

An unemancipated pediatric client is to undergo a routine medical procedure. Who is the appropriate authority to provide consent? 1 The court 2 Either of the child's parents 3 One of the child's grandparents 4 The pediatric client

2 For unemancipated pediatric clients, the parents are required to provide consent. Either parent may do so. The court intervenes in situations where the parents refuse to allow a child to undergo treatment. A grandparent may provide consent only if the situation is an emergency and the parents are not present. The client is underage and unemancipated; therefore if at all possible, consent must be obtained from one of the child's parents in a non life-threatening situation.

A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients? 1 Axilla 2 Oral cavity 3 Temporal artery 4 Tympanic membrane

2 The oral cavity is the preferred site for temperature measurement in adult clients. This site is contraindicated for neonates and unconscious or uncooperative clients. The axilla is a safe site for placing a thermometer in neonates. The temporal artery is indicated for rapid temperature measurement. This site is indicated for premature infants, newborns, and children. The tympanic membrane is indicated in newborns to reduce infant handling and heat loss.

A nursing student is evaluating statements regarding the five levels of proficiency set forth by Benner. Which statement indicates that a nurse is in the advanced beginner stage? 1 The nurse is learning about the profession through a specific set of rules and procedures. 2 The nurse is able to identify the basic principles of nursing care through careful observation. 3 The nurse is able to understand the organization and specific care required by certain clients. 4 The nurse is able to assess the entire situation and transfer knowledge gained from multiple previous experiences.

2 According to the levels of proficiency set forth by Benner, a nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. A nurse in the novice stage learns about the profession through a specific set of rules and procedures. After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients. A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by doing what? 1 Stimulating the urge to defecate 2 Lubricating the sigmoid colon and rectum 3 Dissolving the feces 4 Softening the feces

2 Lubricating the sigmoid colon and rectum The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.

The parents of an adolescent child are worried about their daughter's use of laxatives. Which other behavior in the child does the nurse associate with bulimia nervosa? 1 The child is underweight for her age. 2 The child indulges in binge eating. 3 The child is obsessed with being thin. 4 The child prefers to starve to lose weight.

2 The child indulges in binge eating. Bulimia nervosa is an eating disorder characterized by binge eating and the use of laxatives and self-induced vomiting to prevent weight gain. Anorexia nervosa is a clinical syndrome with both physical and psychosocial components. Clients with anorexia nervosa refuse to maintain body weight at the minimal normal weight for their age and height. An individual with anorexia nervosa has an intense fear of gaining weight. This individual often starves to lose weight.

A nurse who promotes freedom of choice for clients in decision-making best supports which principle? 1 Justice 2 Autonomy 3 Beneficence 4 Paternalism

2 The principle of autonomy relates to the freedom of a person to form his or her own judgments and actions. The nurse promotes autonomy nonjudgmentally so as not to infringe on the decisions or actions of others. Justice means to be righteous, equitable, and to act or treat fairly. Beneficence relates to the state or act of doing good and being kind and charitable. It also includes promotion of well-being and abstaining from injuring others. Paternalism encompasses the practice of governing people in a fatherly manner, especially by providing for their needs without infringing on their rights or responsibilities.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk? 1 Oats 2 Yogurt 3 Potatoes

2 Yogurt

The nurse manager asks the nurse, "How would you implement clinical decision making in a group of clients?" Which answer provided by the nurse shows effective critical thinking? Select all that apply. 1 "I will avoid involving clients as decision-makers and participants in care." 2 "I will discuss complex cases with other members of the healthcare team." 3 "I will identify the nursing diagnoses and collaborative problems of each client." 4 "I will consider the period it takes to care for clients whose problems have higher priority." 5 "I will decide to perform activities individually to resolve more than one client problem at a time."

2 "I will discuss complex cases with other members of the healthcare team." 3 "I will identify the nursing diagnoses and collaborative problems of each client." 4 "I will consider the period it takes to care for clients whose problems have higher priority." The nurse should discuss complex cases with the other members of the healthcare team. It ensures a smooth transition in the care requirements. As a part of effective critical thinking, the nurse should diagnose the collaborative problems of each client. The nurse should consider the care time for the clients having problems that require high priority. Effective critical thinking requires the nurse to involve clients as decision makers or participants in care. The nurse should decide on combining activities to resolve more than one client problem at a time.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1. Limit the client's fluid intake. 2. Teach the client how to exercise the legs. 3. Encourage use of the incentive spirometer. 4. Maintain the knee gatch position at an angle. The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. An incentive spirometer improves pulmonary function, but does not prevent venous stasis. Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal space.

2. Teach the client how to exercise the leg

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1 Lactated Ringer solution 2 5% dextrose and water 3 0.9% normal saline 4 0.45% normal saline

3 0.9% normal saline Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.

How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing? 1 It is a willful act violating a client's rights. 2 It is a civil wrong made against a person or property. 3 It is an act that lacks intent but involves volitional action. 4 It is an unintentional act that includes negligence and malpractice.

3 It is an act that lacks intent but involves volitional action. A quasi-intentional tort lacks intent but involves volitional actions such as invasion of privacy and defamation of character. An intentional tort is a willful act that violates another's rights. This includes assault, battery, and false imprisonment. A tort is a civil wrong made against a person or property. An unintentional tort involves negligence and malpractice.

Which of these is a part of health belief model? 1 Behavioral outcomes 2 Behavior-specific knowledge 3 Perception of susceptibility to an illness 4 Individual characteristics and experience

3 The health belief model is divided into three components. The first component is an individual's perception of susceptibility to an illness. The second component is an individual's perception of seriousness of an illness. The third component is the preventive actions taken by a person. The health promotion model focuses on behavioral outcomes, behavior-specific knowledge and affect, and individual characteristics and experience.

What does the nurse understand by the word felony? 1 A felony is a less serious crime that has a penalty of a fine or imprisonment for less than one year. 2 A felony is the publication of false statements that occurs when one speaks falsely about another. 3 A felony is the publication of false statements that occurs when false entries are made in a medical record. 4 A felony is a crime of a serious nature that has a penalty of imprisonment for longer than one year or even death.

4 A felony is a crime of a serious nature that has a penalty of imprisonment for longer than 1 year or even death. A misdemeanor is a less serious crime that has a penalty of a fine or imprisonment for less than 1 year. Slander is the publication of false statements that occurs when one speaks falsely about another. Libel is the publication of false statements that occurs when false entries are made in the medical record.

A nursing student is listing examples of active and passive health promotion strategies. Which strategy is an example of a passive health promotion strategy? 1 Weight-reduction program 2 Smoking-cessation program 3 Drug abuse prevention strategy 4 Fluoridation of municipal drinking water

4 Passive strategies of health promotion help people benefit from the activities of others without direct involvement. The fluoridation of municipal drinking water is an example of a passive health promotion strategy. Active strategies of health promotion require clients to adopt specific programs for improving health. Weight-reduction programs, smoking-cessation programs, and drug abuse prevention strategies are examples of active health promotion activities.

A nursing student is listing examples of healthcare services. Which scenario is an example of restorative care? 1 Performing radiological procedures on a client who has sustained a heart attack 2 Monitoring the blood pressure of an older adult with insomnia and hypertension 3 Advising a pregnant woman to eat a nutrition-rich diet to avoid any deficiencies in the baby 4 Visiting a private residence to perform maggot-aided debridement therapy of a client's wound

4 Visiting a client's residence to perform maggot-aided wound debridement is an example of restorative care. Performing radiological procedures on a client who has sustained a heart attack is an example of secondary acute care. Monitoring the blood pressure of an older adult with insomnia and hypertension is an example of preventive care. Advising a pregnant woman to eat a nutrition-rich diet to avoid any deficiencies in the baby is an example of primary care.

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months? 1 Holding a pencil 2 Showing hand preference 3 Placing objects into containers 4 Transferring objects from hand to hand

4 Infants of aged 6 to 8 months may be able to transfer objects from hand to hand. Infants of aged 10 to 12 months may be able to hold a pencil. Infants of aged 8 to 10 months may show a hand preference. Infants of aged 10 to 12 months may be able to place objects into a container.

The waiting area of a health care facility displays a pink triangle. What does this signify? 1 The waiting area is for females. 2 The waiting area is for pediatric clients. 3 The health care facility welcomes transwomen. 4 The health care facility welcomes lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) clients.

4 A waiting room in a health care facility marked with a pink triangle indicates that the health care facility is in a safe place for LGBTQ clients, and they can expect respectful and knowledgeable quality care. Other symbols might be used to represent areas that are meant for female and pediatric clients. There are no widely used symbols to designate transwomen-specific health care facilities.

The nurse is assessing a Latino-Caribbean client who was brought to the hospital by family members. The family reports the client started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? 1 Bulimia nervosa 2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervous

4 Ataque de nervous Ataque de nervios is a Latino-Caribbean culture-bound syndrome that usually happens in response to specific stressors. This culture-bound syndrome is characterized by crying, uncontrollable spasms, trembling, shouting, dissociation, and trance-like states. Bulimia nervosa and anorexia nervosa are culture-bound syndromes in the form of eating disorders, but they are not characterized by crying, spasms, and shouting. Shenjing shuairuo is not associated with the Latino-Caribbean culture; instead, it is associated with Chinese culture.

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? 1 Teaching how to make a room allergy-free 2 Referring to a support group for individuals with asthma 3 Arranging with the college to ensure a speedy return to classes 4 Evaluating whether the necessary lifestyle changes are understood

4 Evaluating whether the necessary lifestyle changes are understood Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

The registered nurse teaches a nursing student about the implementation process of nursing. Which example does the registered nurse use while describing indirect care interventions using his or her knowledge? 1 The nurse counseling a client at the time of grief 2 The nurse administering an intravenous infusion to a client 3 The nurse teaching the client about an appropriate nutrition plan 4 The management of the client's environment to prevent infections

4 The management of the client's environment to prevent infections Nursing interventions are based on clinical judgment and knowledge and performed by the nurse for enhancing the client's outcomes. Indirect care interventions are treatments which are performed away from the client but will benefit the client. Managing the client's environment to prevent infection control is an indirect care intervention. Direct care interventions are performed through interactions with the clients. Direct care interventions may include counselling the client at the time of grief, administering an intravenous infusion to the client, and teaching the client about an appropriate nutrition plan.

Which feature according to Benner is observed in a nurse at the "proficient" level? 1 The nurse learns by means of a set of rules. 2 The nurse identifies the principles of nursing care. 3 The nurse identifies problems related to the health care system. 4 The nurse focuses on managing care rather than managing skills.

4 The nurse focuses on managing care rather than managing skills. The nurse at the proficient level has more than 2 or 3 years of experience in the same clinical position. The nurse focuses on managing care rather than managing and performing skills. The novice nurse learns by means of a set of rules, which are usually stepwise and linear. The advanced beginner has observational experience and is able to identify the principles of nursing care. The expert nurse is skilled at identifying client-centered problems, health care system-related problems, and the needs of the novice nurse.

A nurse is caring for a client who had head and neck surgery. Postoperatively, the nurse positions the client's head in functional alignment to prevent what complication? 1 Cervical trauma 2 Laryngeal spasm 3 Laryngeal edema 4 Wound dehiscence

4 Wound dehiscence Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can precipitate wound dehiscence. The cervical vertebrae are designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema.

The nurse who is working during the 8:00 am to 4:00 pm shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift.

970ml 1 ounce = 30 mL; therefore the client ingested 120 mL of orange juice at 8:30 am, 180 mL of tea at 8:30 am, 60 mL of water with medications at 10:00 am, 90 mL of soup at 12:30 am, and 120 mL of ice cream at 12:30 pm (counted as a liquid because it melts at room temperature). The client received 400 mL of IV fluid (50 mL × 8 hours = 400). Total intake is 970 mL. Vomit and urine output should not be included in the client's intake.

The findings of four clients who underwent eye examinations are given below. Which client is suspected to have sustained injury to the cranial nerve III?

Drooping eyelids Injury to the third cranial nerve may result in edema or impairment of the third cranial nerve. This results in the abnormal drooping of the eyelids, a condition called ptosis. Myopia is nearsightedness, a refractive error in which rays of light enter the eye and focus in front of the retina. Cross-eyes result from strabismus, which results from neuromuscular injury or congenital anomaly. Protruding eyes (exophthalmoses) is indicative of hyperthyroidism.

Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions. Correct 1. Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist Correct 2. Apply either a surgical mask or a respirator around the mouth and nose Correct 3. Apply eyewear or goggles snugly around the face and eyes Correct 4. Apply clean gloves within the gown Correct 5. Bring the glove cuffs over the edge of the gown sleeves.

Placed in correct order When preparing to enter an isolation room [1] [2], the nurse first needs to apply a cover gown pull the sleeves down to wrist, and tie securely at neck and waist. The nurse should wear either a surgical mask or a respirator around his or her mouth and nose. If necessary, apply eyewear or goggles snugly around the face and eyes. Next, the nurse should wear gloves within the gown and pull the glove cuffs over the gown sleeves.

The nurse is caring for a client who requires an intravenous infusion. The nurse explains the reason for the procedure while assembling the kit for the infusion. What is the role of the nurse in this situation? 1 Educator 2 Manager 3 Advocate 4 Caregiver

1 Educator The nurse assumes the role of educator when explaining to the client the need for an intravenous infusion. The nurse as a manager oversees the budget of a specific nursing unit or agency and is also responsible for coordinating the activities of the staff providing nursing care. As an advocate, the nurse protects the human and legal rights of the client. The nurse empowers the client with information required to make important health care decisions. The nurse is a caregiver when helping the client maintain and regain health, manage disease symptoms, and achieve a maximum level of functioning.

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning? 1 "I will ask the client to move his or her arm towards the body." 2 "I will ask the client to bend his or her limb by decreasing the angle." 3 "I will ask the client to move his or her hand so that the ventral surface faces downward." 4 "I will ask the client to move his or her head beyond its normal resting extended position."

1 "I will ask the client to move his or her arm towards the body." Adduction is moving the arm towards the body. Assessing the range of motion by bending the limb and decreasing the angle indicates flexion. Moving the hand by facing the ventral surface downwards indicates pronation. The movement of the head beyond the normal resting extended position indicates hyperextension.

A registered nurse is educating a nursing student about the stages of changes in a client's health behavior. Which statement describes the stage of contemplation? 1 "The client considers a change within the next 6 months." 2 "The client does not intend to make changes within the next 6 months." 3 "The client is actively engaged in strategies to change behavior; this lasts up to 6 months." 4 "The client displays sustained change over time; this begins 6 months after action has started and continues indefinitely."

1 "The client considers a change within the next 6 months." In the contemplation stage, the client considers a change within the next 6 months. In the precontemplation stage, the client does not intend to make changes within the next 6 months. In the action stage, the client is actively engaged in strategies to change behavior. This stage lasts up to 6 months. When sustained change is noticed over time and begins 6 months after action has started and continues indefinitely, the client has reached the maintenance stage.

Which assessments should the nurse perform while assisting an older adult with housing needs? Select all that apply. 1 Assessing financial status 2 Assessing meaningful activities and interest 3 Assessing environmental hazards and support systems 4 Assessing long range plans such as wills and advance directives 5 Assessing access to public transportation and community activities

1 Assessing financial status 3 Assessing environmental hazards and support systems 5 Assessing access to public transportation and community activities When assisting an older adult with his or her housing needs, the nurse should assess the client's financial status, environmental hazards, support systems, and access to public transportation and community activities. When an older adult is planning for retirement, the nurse should assess the client's meaningful activities and interest and long range plans including wills and advanced directives.

How can a nurse best evaluate the effectiveness of communication with a client? 1 Client feedback 2 Medical assessments 3 Health care team conferences 4 Client's physiologic responses

1 Client feedback Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

What purpose does a community health center serve in preventive and primary care services? 1 Community health centers are outpatient clinics that provide primary care to a specific population. 2 Community health centers aim to increase worker productivity, decrease absenteeism, and reduce the use of costly medical care. 3 Community health centers emphasize program management, interdisciplinary collaboration, and community health principles. 4 Community health centers include a complete program designed for health promotion and accident or illness prevention in the workplace.

1 Community health centers are outpatient clinics that provide primary care to a specific population. Community health centers are outpatient clinics that provide primary care to a specific population, such as clients with young children or clients with diabetes. Occupational health services aim to increase worker productivity, decrease absenteeism, and reduce the use of costly medical care. School health services emphasize program management, interdisciplinary collaboration, and community health principles. Occupational health services include a complete program designed for health promotion and accident or illness prevention in the workplace

Health promotion efforts for a chronically ill client should include interventions related to primary prevention. What should this include? 1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications

1 Encouraging daily physical exercise Primary prevention activities are directed toward promoting a healthful lifestyle and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimal level of functioning.

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1 Focusing 2 Restating 3 Exploring 4 Accepting

1 Focusing Focusing is a technique that directs a client back to the original topic of discussion. Restating the main idea of what the client has said encourages the client to continue speaking or clarifies what has been said. Exploring permits the nurse to delve deeper into the subject when the client tends to stay on a superficial level. Accepting is a technique used to understand and demonstrate regard for what the client stated.

A nursing student lists examples of health promotion activities that can help clients maintain or enhance their present levels of health. Which examples are accurate? Select all that apply. 1 Good nutrition 2 Regular exercise 3 Physical awareness 4 Immunization against measles 5 Education about stress management

1 Good nutrition 2 Regular exercise

The school nurse conducts a class in nutrition planning for parents. What is the goal of school health nursing programs? 1 Health promotion 2 Disease management 3 Chronic care management 4 Environmental surveillance

1 Health promotion The goal of school health nursing programs is health promotion through a school curriculum. A class on nutritional planning for parents contributes to health promotion. Disease management is one of the many programs of community health centers. These centers provide primary care to a specific client population within a community. Nurse-managed clinics provide nursing care with a focus on acute and chronic care management. The occupational health nurse may conduct an environmental surveillance for health promotion and accident prevention in the work setting.

A nurse has made a nursing diagnosis without validating the data obtained from the client. Into what category does this error fall? 1 Labeling 2 Collecting 3 Clustering 4 Interpreting

1 Labeling

The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate? Select all that apply. 1 Palpating for tenderness 2 Observing nonverbal cues 3 Inspecting any areas of discomfort 4 Noticing if the pain localized or radiated 5 Noticing if the client gives nonverbal signs of pain

1 Palpating for tenderness 3 Inspecting any areas of discomfort

The nurse working in a palliative care setting identifies that which members of the health care team provide ancillary services to clients? Select all that apply. 1 Pharmacists 2 Spiritual advisors 3 Occupational therapists 4 Primary health care providers 5 Unlicensed Assistive Personnel (UAP)

1 Pharmacists 3 Occupational therapists 5 Unlicensed Assistive Personnel (UAP) Pharmacists, Unlicensed Assistive Personnel, and occupational therapists provide ancillary services to the client. They support the care of the client and the needs of the client's family. The primary healthcare provider evaluates and assesses clinical manifestations, diagnoses the client's illness, and provides treatment. Spiritual advisors provide spiritual care to the client.

Which statement is true about prescriptive theories? 1 Prescriptive theories are action-oriented. 2 Prescriptive theories help to explain client assessment. 3 Prescriptive theories focus on a specific field of nursing. 4 Prescriptive theories are the first level of theory development

1 Prescriptive theories are action-oriented. Prescriptive theories are action-oriented. They test the validity and predictability of a nursing intervention. These theories address nursing interventions for a phenomenon, describe the conditions under which the prescription occurs, and predict the consequences. Descriptive theories help to explain client assessment. A middle-range theory tends to focus on a specific field of nursing. Descriptive theories are the first level of theory development.

Which basic human needs belongs to the fourth level as per Maslow's hierarchy of needs? Select all that apply. 1 Self-worth 2 Achievement 3 Security needs 4 Belonging needs 5 Self-actualization

1 Self worth 2 Achievement Fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness? 1 Applying moisturizing lotion between toes 2 Cutting nails after soaking them for 10 minutes in warm water 3 Cutting nails straight across and even with the tops of the fingers or toes 4 Using sharp objects to poke or dig under the toenail or around the cuticle

2 Cutting nails after soaking them for 10 minutes in warm water Normally, nails should be cut after soaking them in warm water for 10 minutes. This action should not be performed for diabetic clients because soaking the nails will dry out the hands and feet, which may lead to infection. Applying moisturizing lotion between the toes will promote microorganism growth; it will not dry the skin. Cutting nails straight across and even with the tops of the fingers or toes is the proper way to maintain nail hygiene. Diabetic clients are advised not to use sharp objects to poke or dig under the toenails or around the cuticles to avoid injury to the skin.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? 1 Sit down quietly next to the bed and allow her to cry. 2 Pull the curtain and leave the room to provide privacy for the client. 3 Explain to the client that her feelings are expected and they will pass with time. 4 Observe the length of time the client cries and document her difficulty accepting her impending death.

1 Sit down quietly next to the bed and allow her to cry. Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion without enough information.

A nurse is teaching a parent about the different temperaments that a child may display. What characteristics does a slow-to-warm up child display? Select all that apply. 1 The child adapts slowly with frequent communication. 2 This child is regular and predictable in his or her habits. 3 The child is highly active, irritable, and irregular in his or her habits. 4 The child reacts with mild but passive resistance to novelty. 5 The child reacts negatively and with mild intensity to new stimuli.

1 The child adapts slowly with frequent communication. 4 The child reacts with mild but passive resistance to novelty. 5 The child reacts negatively and with mild intensity to new stimuli. A slow-to-warm up child adapts slowly with frequent communication and reacts to novelty with mild but passive resistance. A slow-to-warm up child also reacts negatively and with mild intensity to new stimuli. An easy child is regular and predictable in his or her habits. A difficult child is highly active, irritable, and irregular in his or her habits.

During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the clinical record. Legally, how should the nurse's action be interpreted? 1 The nurse performed her role correctly. 2 This is a medical diagnosis and the nurse overstepped the legal boundary. 3 Nursing assessments are not equivalent to a primary healthcare provider's assessments. 4 The initial assessment of the infant's physical status is the responsibility of the client's primary healthcare provider.

1 The nurse performed her role correctly. Accurate documentation of the infant's status is an integral component of nursing care. This is a physical assessment, not a medical diagnosis, and is within the nurse's role. Assessments should not differ when done by the nurse. The nurse is capable of independently performing a physical assessment.

An isolated older adult is diagnosed with cancer and fears death. Which intervention provided would help to induce relaxation and to communicate interest in the client? 1 Touch 2 Reminiscence 3 Reality orientation 4 Therapeutic communication

1 Touch Touch is a therapeutic tool that helps induce relaxation, provide physical and emotional comfort, and communicate interest in an older adult. Reminiscence helps to bring meaning and understanding to the client's present situation and resolves current conflicts by recollecting the past. Reality orientation involves making an older adult more aware of time, place, and person. Therapeutic communication helps to perceive and respect the older adult's healthcare expectations.

The nurse is entering a client's data in the electronic health record. What action should the nurse take to minimize ambiguity and confusion? 1 Use consistent, codified terminology. 2 Record the data in the client's presence. 3 Enter the data in the client's native language. 4 Upload scanned copies of the client's records.

1 Use consistent, codified terminology An electronic health record is a client's official digital health record and is shared among multiple facilities and agencies. Therefore the nurse must use consistent, codified terminology to eliminate ambiguity and confusion. Recording the data in the presence of the client will not help another health care professional understand the data. Healthcare providers review electronic health record for continuing a client's treatment. Therefore the nurse should enter client data by using a clear codified scheme, not in the client's native language. The nurse should not upload scanned copies of client records because others may not understand the nurse's handwriting and may get confused.

A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote what? 1 Dental health 2 Growth and development 3 Improved hearing 4 Night vision

1 Dental Health Fluoride, or fluorine, is an element necessary for good dental health that helps to harden tooth enamel and decrease dental caries. Natural food sources may not be adequate; therefore fluoride is added to drinking water to help meet the recommended daily requirements. Growth and development, hearing, and night vision are not direct influences of fluorine intake.

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? 1 Primary nurse 2 Nurse clinician 3 Nurse coordinator 4 Clinical nurse specialist

1 Primary nurse The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or healthcare provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. Clinical nurse specialist is a title given to a nurse specially prepared for one very specific clinical role. It requires a master's degree level of education.

Which standards would the nurse explain are important for critical thinking? Select all that apply. 1 Specific 2 Fairness 3 Relevant 4 Confidence 5 Independence

1 Specific 3 Relevant The standards important for critical thinking are specific and relevant knowledge about a task. Fairness, confidence, and independence are the attitudes required for critical thinking.

The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the student nurse indicates the need for further education? 1 "I should set up and prepare medications in distraction-free areas." 2 "I should advise the certified medical assistant to administer intravenous medication." 3 "I should be vigilant during the entire process of medication administration." 4 "I should identify each client using at least two identifiers before administrating medications."

2 "I should advise the certified medical assistant to administer intravenous medication." Certified medical assistants are eligible to administer PO (by mouth) medications in long-term care settings in some areas. The nurse should set up and prepare medications in distraction-free areas. The nurse should be vigilant during the entire process of medication administration. The nurse should identify each client using at least two identifiers before administering medications.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? 1 "Wear sterile gloves when doing the procedure." 2 "Wash your hands before performing the procedure." 3 "Perform the self-catheterization every 12 hours." 4 "Dispose of the catheter after you have catheterized yourself."

2 "Wash your hands before performing the procedure." To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what? 1 Providing instructions about restraints used during the procedure 2 Administering a Fleet enema 1 hour before the procedure 3 Encouraging increased intake of clear fluids 4 Administering morphine 30 minutes before the procedure

2 Administering a Fleet enema 1 hour before the procedure To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A Fleet or tap water enema should be used. Restraints are not typically used during the procedure. The client will be kept nothing by mouth (NPO) for at least 8 hours before the procedure. Morphine is not typically used as a preoperative medication before a sigmoidoscopy.

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially? 1 Encourage the client to exercise during the day. 2 Arrange a referral for a thorough medical evaluation. 3 Explain that this behavior is an attempt to avoid facing daily responsibilities. 4 Identify that the client is describing clinical findings associated with narcolepsy.

2 Arrange a referral for a thorough medical evaluation.

A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be most appropriate to obtain the client's temperature? 1 Oral 2 Axilla 3 Temporal artery 4 Tympanic membrane

2 Axilla

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? 1 Care that supports physical functioning 2 Care that supports homeostatic regulation 3 Care that supports psychosocial functioning 4 Care that provides immediate short-term help in physiological crises

2 Care that supports homeostatic regulation Providing perioperative care (care before, during, and immediately after surgery) involves care that supports homeostatic regulation. If interventions are provided to support the client in doing daily activities, they are considered a physiological basic domain that supports physical functioning. Providing behavioral and cognitive therapies helps to support psychosocial functioning and facilitates lifestyle changes. Providing immediate short-term help in physiological crises helps to support protection against harm.

An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client? 1 Clinical nurse specialist (CNS) Certified nurse midwife (CNM) 3 Certified nurse practitioner (CNP) 4 Certified registered nurse anesthetist (CRNA)

2 Certified nurse midwife (CNM) A certified nurse midwife (CNM) is qualified and has the skills to care for a pregnant woman. A clinical nurse specialist (CNS) is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. A certified nurse practitioner (CNP) is an APRN who provides healthcare to a group of clients, usually in an outpatient, ambulatory care, or community-based setting. A certified registered nurse anesthetist (CRNA) is an APRN with an advanced education in a nurse anesthesia accredited program.

Which theory describes the phenomenon of grief or caring? 1 Grand theories 2 Descriptive theories 3 Prescriptive theories 4 Middle-range theories

2 Descriptive theories Descriptive theories describe a phenomenon such as grief or caring. Grand theories provide the structural framework for broad, abstract ideas about nursing. Prescriptive theories discuss interventions and expected outcomes for a specific phenomenon. They describe phenomena, speculate on why they occur, and describe their consequences. Middle-range theories have a more narrow scope than grand theories; these theories integrate theory-based research with nursing practices.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1 Rapid, thready pulse 2 Distended jugular veins 3 Elevated hematocrit level 4 Increased serum sodium level

2 Distended jugular veins Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do? 1 Assess the strength of the affected leg. 2 Explain the transfer procedure step by step. 3 Instruct the client to bear weight evenly on both legs. 4 Encourage the client to keep the affected leg elevated.

2 Explain the transfer procedure step by step.

A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? 1 Perform a finger stick glucose test and call the primary healthcare provider with the results. 2 Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. 3 Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready. 4 Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.

2 Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may perform a finger stick glucose test and notify the healthcare provider if the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at keep vein open (KVO) until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless there is a negative client outcome that results.

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount? 1 Plasma 2 Interstitial 3 Dense tissue 4 Body secretions

2 Interstitial Interstitial fluid constitutes about 16% of body weight, which is 10 to 12 L in an adult male of 68 kg (150 lb). Plasma is 4% of body weight. Dense tissue is part of the intracellular component. Body secretions are derived from extracellular fluid and are calculated as part of the 20% of the total body weight.

Which action correlates with the relevance strategy of the motivational learning model proposed by John Keller? 1 Extrinsic and intrinsic reinforcements for any learning effort 2 Linking the person's needs, interests, and motives for learning 3 Arousing and sustaining a person's curiosity and interest in learning 4 Having positive hope for successful achievements as a result of learning

2 Linking the person's needs, interests, and motives for learning John Keller proposed a motivational learning model that includes four factors: attention, relevance, confidence, and satisfaction (ARCS). Relevance strategies involve linking the person's needs, interests, and motives for learning. The attention strategies include arousing and sustaining one's curiosity and interest. Confidence strategies include helping people develop a positive expectation for goal achievement. Satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts.

What are the important points to be considered when imparting practical knowledge to nursing students about preventing complications in the hospital? Select all that apply. 1 Nursing students are not accountable if a client is harmed. 2 Nursing students should never be assigned any tasks they are unprepared for. 3 Nursing students are employees of the hospital and may act as witnesses to consent forms. 4 Nursing students can work as nursing assistants or nurse's aides when not attending classes. 5 Nursing students should notify the nursing supervisor in case they are delegated tasks they are not prepared for.

2 Nursing students should never be assigned any tasks they are unprepared for. 4 Nursing students can work as nursing assistants or nurse's aides when not attending classes. 5 Nursing students should notify the nursing supervisor in case they are delegated tasks they are not prepared for. Nursing students should never be assigned to perform tasks for which they are unprepared. A nursing student can work as a nursing assistant or a nurse's aide when not attending classes. In case anyone instructs a nursing student to perform a task that he or she is unprepared for, the nursing supervisor should be notified as soon as possible. A nursing student is indeed accountable if a client is harmed. A nursing student is not an employee of the hospital and he or she cannot act as a witness to consent forms because these forms are legal documents.

Identify factors associated with an increased incidence of abuse within a family. Select all that apply. 1 Acute illness 2 Pregnancy 3 Drug abuse 4 Chronic illness 5 Sexual orientation

2 Pregnancy 3 Drug abuse 5 Sexual orientation Pregnancy, drug abuse, and sexual orientation are associated with an increased incidence of abuse within a family. Acute and chronic illness may place stress on the family, but these factors are not specifically linked to a higher incidence of violence.

While reviewing a client's prescriptions, the nurse finds that one of the prescribed drugs is redundant and notifies the primary healthcare provider. Which attitude of critical thinking does the nurse exhibit? 1 Curiosity 2 Risk taking 3 Thinking independently 4 Responsibility and authority

2 Risk taking If the nurse questions a healthcare provider's order by applying his or her knowledge, then this attitude is considered risk taking. If a nurse explores and learns more about a client to make appropriate judgments, then the attitude is curiosity. Thinking independently is indicated when a nurse reads nursing literature that provides multiple viewpoints on the same subject. The responsibility and authority of a nurse is shown by asking for help, reporting problems immediately, and following proper procedures.

Which point is included in the World Professional Association for Transgender Health (WPATH) document regarding core principles of care for transgender clients? 1 Designating unisex or single-stall restrooms 2 Seeking informed consent before providing treatment 3 Posting the patient's bill of rights and nondiscrimination policies visibly 4 Reflecting the client's choice of terminology in communication and documentation

2 Seeking informed consent before providing treatment The nurse must seek informed consent before providing treatment for a transgender client. This is one of the core principles for health care professionals who care for transgender clients as per the document published by the World Professional Association for Transgender Health (WPATH). As per The Joint Commission recommendations for creating a safe and welcoming environment for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) clients, the nurse should designate unisex or single-stall restrooms, post the patient's bill of rights and nondiscrimination policies visibly, and use the client's choice of terminology in communication and documentation.

Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? 1 Sharing hope 2 Sharing humor 3 Sharing empathy 4 Sharing observations

2 Sharing humor Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses should recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client to communicate without the need for extensive questioning, focusing, or clarification.

While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? Select all that apply. 1 Heart 2 Vagina 3 Rectum 4 Female genitalia 5 Musculoskeletal system

2 Vagina 3 Rectum

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? 1 "I should serve food that is easy to eat." 2 "I should assist the client with eating." 3 "I should monitor weight and food intake once in a month." 4 "I should offer food supplements that are tasty and easy to swallow."

3 "I should monitor weight and food intake once in a month." The nurse should monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse should serve food that is easy to eat provide assistance with eating. The nurse should also offer food supplements that are tasty and easy to swallow.

What information should the nurse provide when explaining the benefits of illness prevention activities to a client? 1 "These activities aim to teach people how to care for their own health." 2 "These activities enable people to maintain or enhance their health levels." 3 "These activities help protect clients from actual or potential health threats." 4 "These activities encourage people to reach an optimal state of physical, mental, and social well-being."

3 "These activities help protect clients from actual or potential health threats." Illness prevention activities help protect clients from actual or potential health risks and threats. Nurses impart wellness education to people to teach them to care for themselves in a healthy way. Health promotion activities enable clients to maintain or enhance their health levels. These activities also help people to reach an optimal state of physical, mental, and social well-being. Routine exercise and good nutrition are examples of health promotion activities.

A client has a right-above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best response? 1 "Tell me what you think happened." 2 "You will remember more as you get better." 3 "You were in a work-related accident this morning." 4 "It was necessary to amputate your leg after the accident."

3 "You were in a work-related accident this morning." The correct response is truthful and provides basic information that may prompt recollection of what occurred; it is a starting point. Asking the client to tell the nurse what happened ignores the client's question; avoidance may increase anxiety. Saying "you will remember more as you get better" ignores the client's question; the frustration of trying to remember will increase anxiety. Saying "it was necessary to amputate your leg after the accident" is too blunt for the initial response to the client's question; the client may not be ready to hear this at this time.

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding? 1 Procedures for a client's benefit do not require a signed consent. 2 Clients who are aphasic are incapable of signing an informed consent. 3 A separate signed informed consent for routine treatments is unnecessary. 4 A specific intervention without a client's signed consent is an invasion of rights.

3 A separate signed informed consent for routine treatments is unnecessary. This is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

Which of these cultural groups adopts a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness? 1 East Asian 2 Hispanic 3 Asian Indian 4 Native American

3 Asian Indian Asian Indians rely on a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness. East Asians use yin treatment (which uses needles to restore balance and flow of qi) and yang treatment (which uses moxibustion or heat with acupuncture to restore the yin/yang balance). Hispanics use a combination of prayers, herbs, and other rituals to treat traditional illnesses. Native Americans rely on a combination of prayers, chanting, and herbs to treat illnesses caused by supernatural, psychologic, and physical factors.

Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of EHRs? 1 National Institute of Health (NIH) 2 American Medical Informatics Association (AMIA) 3 Center for Medicare and Medicaid Services (CMS) 4 Health Information Management Systems Society (HIMSS)

3 Center for Medicare and Medicaid Services (CMS) CMS rules specify how health care facilities and providers make meaningful use of the EHRs and technologies to receive payment from Medicare and Medicaid. The National Institutes of Health uses translational bioinformatics for medical research. The American Medical Informatics Association and the Health Informatics Management Systems Society have been involved in identifying nursing informatics competencies.

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? 1 Plan to discuss this with the client's family. 2 Identify personal feelings toward this client so one can share feelings. 3 Develop a rapport with the client so one can offer more supportive care. 4 Explore the client's emotional conflict in detail so it can be documented in the medical record.

3 Develop a rapport with the client so one can offer more supportive care. Nurses should explore their own feelings prior to caring for this client population. Then they should establish rapport with the client in order to provide more supportive care. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.

A nursing student lists the preventive and primary care services available in schools, primary healthcare provider's offices, occupational health clinics, community health centers, and nursing centers. Which service provided by these centers is most expensive? 1 Running errands 2 Health education 3 Disease management 4 Routine physical examinations

3 Disease management Disease management is the most expensive service provided by community health centers. Running errands is inexpensive, and if the person walks or rides a bike, can be used as a health promotion activity. Health education and routine physical examinations are inexpensive and can usually stop complications of diseases, which prevents from having to "manage" diseases, leading to costly and expensive treatment.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to? 1 Analysis 2 Evaluation 3 Explanation 4 Interpretation

3 Explanation

The nurse is preparing to insert an intravenous catheter in a thin, emaciated client who is scheduled to begin intravenous fluid therapy. Which interventions should the nurse follow to provide high-quality care? Select all that apply. 1 Insert an 18 gauge IV catheter 2 Change the intravenous line every 7 days 3 Flush the intravenous line with normal saline 4 Insert the intravenous catheter in the client's femur 5 Stop the insertion procedure when there is a break in technique

3 Flush the intravenous line with normal saline 5 Stop the insertion procedure when there is a break in technique The nurse should flush the IV line with normal saline to maintain patency. The nurse should stop the insertion procedure when there is a break in technique. This intervention helps prevent catheter-related bloodstream infections and provides high-quality care to the client. An 18-gauge needle is not an appropriate size needle to insert in a thin, emaciated client; it would cause unnecessary trauma and a high risk of phlebitis. The nurse should change the intravenous line every 72 to 96 hours to prevent the risk of infection. The nurse should avoid inserting the catheter in the client's femur because it increases the risk of bloodborne infections.

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? 1 Industry versus inferiority 2 Identity versus role confusion 3 Generativity versus stagnation 4 Autonomy versus shame/doubt

3 Generativity versus stagnation The generativity versus stagnation stage precedes integrity versus despair; Erikson theorized that how well people adapt to a present stage depends on how well they adapted to the immediately preceding stage. Industry versus inferiority is the stage of school-age children; it precedes identity versus role confusion, not integrity versus despair. Identity versus role confusion is the stage of adolescence; it precedes intimacy versus isolation, not integrity versus despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity versus despair.

What legal complications might a nurse face for using a restraint without a legal warrant on a client? 1 The nurse may be charged with libel. 2 The nurse may be charged with negligence. 3 The nurse may be charged with malpractice. 4 The nurse may be charged with false imprisonment.

4 The nurse may be charged with false imprisonment. If a nurse uses restraints without a legal warrant on a client, he/she may be charged with false imprisonment. Libel is the written defamation of character. Negligence is any conduct that falls below the standard of care. Malpractice is a type of negligence that is regarded as professional negligence.

Which nursing interventions can help a terminally ill client cope with feelings related to death? Select all that apply. 1 Providing medications and therapies for pain management 2 Teaching the client about importance of complementary medicine 3 Helping the client to find meaning and purpose in life by listening to his or her concerns 4 Allowing time for religious readings, spiritual visitations, or attendance at religious services 5 Encouraging the client to pray if he or she wishes by facilitating privacy and a proper environment

3 Helping the client to find meaning and purpose in life by listening to his or her concerns 4 Allowing time for religious readings, spiritual visitations, or attendance at religious services 5 Encouraging the client to pray if he or she wishes by facilitating privacy and a proper environment Feelings of connectedness are important for the client who is terminally ill; therefore, the nurse should promote connectedness by helping the client find meaning and purpose in life by listening to his or her concerns. Prayer and devotion can help the client cope with feelings related to death, so the nurse should allow time for religious readings, spiritual visitations, or attendance at religious services. The nurse can also encourage the client to pray if he or she wishes by facilitating privacy and a proper environment. To help the client to cope with the pain, the nurse should provide medications and therapies for pain management. To help the client manage other aspects of the illness, the nurse can educate the client about complementary medicine.

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what? 1 Relieve bronchial spasms 2 Increase depth of respirations 3 Loosen pulmonary secretions 4 Expel carbon dioxide from the lungs

3 Loosen pulmonary secretions Postural drainage and percussion also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

What is the priority nursing intervention for a client during the immediate postoperative period? 1 Monitoring vital signs 2 Observing for hemorrhage 3 Maintaining a patent airway 4 Recording the intake and output

3 Maintenance of a patent airway is always the priority, because airway obstruction impedes breathing and may result in death. Monitoring vital signs, observing for hemorrhage, and recording the intake and output is important; however, a patent airway is the priority.

Which nursing action is not likely to cause legal issues? 1 Using restraints on a non-cooperative client 2 Refraining from reporting suspected child abuse 3 Refraining from leaving the client during a staffing shortage 4 Allowing nursing assistive personnel (NAP) to administer medications

3 Refraining from leaving the client during a staffing shortage The nurse should not abandon clients if there is a staffing shortage. This action helps to avoid legal complications. Using restraints without the order of the primary healthcare provider may lead to battery and false imprisonment charges. The nurse should always report cases of suspected child abuse. A nurse should never allow nursing assistive personnel (NAP) to administer medications because this action may lead to malpractice charges.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1 Skeletal and nervous 2 Circulatory and urinary 3 Respiratory and urinary 4 Muscular and endocrine

3 Respiratory and urinary Increased respirations blow off carbon dioxide (CO2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

A terminally ill client has died in the hospital and it is time to inform the client's family members. The nurse is unsure how to console the family members. Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family? 1 Primary health care provider 2 Pharmacist 3 Social worker 4 Occupational therapist

3 Social worker The social worker on the interprofessional team helps the family members prepare for the client's death and also during the grief and bereavement process. Therefore, the nurse involves the social worker in consoling the family members in this situation. The primary health care provider and pharmacist may not be involved in consoling the family members after the client's death, nor may the occupational therapist be involved at this stage.

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? 1 Maligning a person's character while threatening to do bodily harm 2 A legal wrong committed by one person against property of another 3 The application of force to another person without lawful justification 4 Behaving in a way that a reasonable person with the same education would not

3 The application of force to another person without lawful justification Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons, not property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence.

While reviewing the performance of a newly appointed nurse, the chief operational officer finds that the nurse excels at using reflective journaling. What activity of the nurse would lead the chief operational officer to this conclusion? 1 The nurse shares constructive criticism with his or her team members. 2 The nurse meets with colleagues regularly to discuss work experience. 3 The nurse recalls, thinks, analyzes and learns from day-to-day work situations. 4 The nurse organizes or connects information in a way so the diverse information about a client forms meaningful patterns.

3 The nurse recalls, thinks, analyzes and learns from day-to-day work situations. Reflective practice is a conscious process of recalling, thinking, analyzing, and learning from work situations. This practice may also include journaling work experiences for self-evaluation. Meeting with colleagues to share constructive criticism and discuss work experiences is an important part of critical skill development. The use of concept mapping requires the nurse to organize and collect the client's information in a way that forms meaningful patterns.

A client with a leg fracture is hospitalized. The registered nurse instructs the nursing student to interrogate the client to ascertain the reason for the injury. Which question would help to determine an extrinsic factor? 1 Do you have clear vision? 2 Are you taking any sedatives or hypnotics? 3 Were you wearing inappropriate shoes? 4 Do you have a history of postural hypotension?

3 Were you wearing inappropriate shoes? Extrinsic factors include environmental hazards outside and within the home. Asking the client about his or her footwear will help to ascertain whether there was an extrinsic factor that may have caused the fall. Intrinsic factors include impaired vision, the taking of sedatives or hypnotics, and a history of a postural hypotension.

A registered nurse is explaining the Quality and Safety Education for Nurses (QSEN) competencies to a nursing student. What information should the nurse provide about the competency teamwork and collaboration? 1 "A nurse should be able to use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making." 2 "A nurse should be able to understand that the client is the source of control and full partner when providing compassionate and coordinated care." 3 "A nurse should be able to implement improvement methods to design and test changes in order to improve the quality and safety of the healthcare system." 4 "A nurse should be able to work effectively within nursing and interprofessional teams by promoting open communication and shared decision-making to provide client care."

4 "A nurse should be able to work effectively within nursing and interprofessional teams by promoting open communication and shared decision-making to provide client care." According to the QSEN competency called teamwork and collaboration, a nurse should be able to work effectively within nursing and interprofessional teams, promoting open communication and shared decision-making to provide quality client care. According to the QSEN competency called informatics, a nurse should be able to use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. This helps to deliver optimal healthcare. As per the QSEN competency called patient-centered care, a nurse should be able to understand that the client is the source of control and full partner when the healthcare team provides compassionate and coordinated care. According to the QSEN competency called quality improvement, a nurse should be able to implement improvement methods to design and test changes in order to improve the quality and safety of the healthcare system.

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? 1 Kidney dysfunction 2 Cardiovascular diseases 3 Eye problems, such as glaucoma 4 Accidents, including their prevention

4 Accidents, including their prevention' Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

Which theory is based on the model of primacy of caring? 1 Roy's Theory 2 Watson's Theory 3 Betty Neuman's Theory 4 Benner and Wrubel's Theory

4 Benner and Wrubel's Theory The model of primacy of caring is the basis of Benner and Wrubel's Theory. This theory focuses on client's need for caring as a means of coping with stressors of illness. According to Roy's theory, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity in regard to the humanistic aspects of life. This theory promotes health, restoring the client to health, and preventing illness. Neuman's theory is based on stress and the client's reaction to the stressor.

What principle must a nurse consider when caring for a client with a closed wound drainage system? 1 Gravity causes fluids to flow down a pressure gradient. 2 Fluid flow rate is determined by the diameter of the lumen. 3 Siphoning causes fluids to flow from one level to a lower level. 4 Fluids flow from an area of higher pressure to one of lower pressure.

4 Fluids flow from an area of higher pressure to one of lower pressure. A portable wound drainage system has negative pressure; a nurse must ensure that the collection chamber is compressed so that fluid flows down the pressure gradient from the client to the collection device. Newton's law of gravity is not the physical principle underlying the functioning of a portable wound drainage system. Although fluid flow rate is determined by the diameter of the lumen and siphoning causes fluids to flow from one level to a lower level, they are not what cause the fluid to drain in a portable wound drainage system.

Which statement is true about the nursing model "team nursing"? 1 The registered nurse is responsible for all aspects of client care. 2 Client care can be delegated to other healthcare team members. 3 The registered nurse works directly with the client, family members, and healthcare team members. 4 Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

4 Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.

Which step in the nursing process would involve promoting a safe environment for the client? 1 Planning 2 Diagnosis 3 Assessment 4 Implementation

4 Implementation The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client's health and situation during the assessment stage.

A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? 1 Family in later life 2 Family with adolescents 3 Unattached young adult 4 Launching children and moving on

4 Launching children and moving on The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescents stage of the family lifecycle involves establishing flexible boundaries to accommodate the growing child's independence. An individual experiencing the unattached young adult stage begins to differentiate themselves from his or her family of origin. The young adult establishes him or herself at work while the young adult's parents experience the launching children and moving on stage.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? 1 Suddenness of the change 2 Obviousness of the change 3 Extent of the change 4 Perception of the change

4 Perception of the change It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

The student nurse is reviewing the electronic health record for clients in a health care facility. Which action by the student nurse may inhibit clients from disclosing personal information? 1 Use of clients' data for nursing research 2 Use of client data for Medicaid payment 3 Discussing a client's illness with the client 4 Sharing clients' data with family members

4 Sharing clients' data with family members Clients may not want their health information shared with others and may want to maintain their privacy. If the nurse retrieves client data from the electronic health records and shares it with family members, it may lead to clients not sharing information. The nurse can use client data for research without mentioning a client's personal details. The nurse can use client data for filing insurance to receive Medicaid payments. The nurse can discuss the client's illness with the client; doing so helps to understand the client's perspective and to provide effective care.

The nurse plans care for a client who has anxiety related to uncertainty over the course of recovery. Which action of the client would indicate that the desired goal is achieved? 1 The client discusses the surgical outcomes with the surgeon. 2 The client shares concerns with the spouse before discharge. 3 The client describes the effects surgery will have on recovery. 4 The client expresses acceptance of health status by the day of discharge.

4 The client expresses acceptance of health status by the day of discharge. A goal is a desired change in a client's condition or behavior. Therefore, when a client who is anxious about the disease recovery starts expressing acceptance of his or her health status by the day of discharge, it reflects that the desired nursing goal is achieved. The client sharing concerns, describing effects of surgery on recovery, and discussing surgical outcomes shows partial achievement of the goals (expected outcomes).

A nursing student is recalling the order of priority for giving consent to perform an autopsy in cases where a medical examiner review is not needed. Which person receives the highest priority for giving consent? 1 Surviving child 2 Surviving parent 3 Surviving spouse 4 The client in writing before death

4 The client in writing before death If a medical examiner's review is not necessary, the highest priority is given to the client. The client may provide the consent in writing before death. If the client or the surviving spouse is unable to give consent for the autopsy, a surviving child may be requested to give consent. The surviving parent may give consent for an autopsy if the client, the surviving spouse, and the surviving child are unable to do so. In case the client has not provided written consent before death, the nurse may obtain consent from the surviving spouse.

What is the goal of Healthy People 2020? 1 To ensure the well-being of clients cared for in a hospital setting 2 To encourage the nurse to do good for the client 3 To have the nurse act as an advocate for clients who are not capable of self-determination 4 To eliminate health disparities related to race, ethnicity, and socioeconomic status

4 To eliminate health disparities related to race, ethnicity, and socioeconomic status The primary goal of Healthy People 2020 is to eliminate health disparities related to race, ethnicity, and socioeconomic status. This helps to increase the quality of health care and help people live longer. Nonmaleficence is the ethical concept that emphasizes the importance of preventing harm and ensuring the client's well-being. Beneficence is the ethical concept that encourages the nurse to do good for the client. According to the American Nurses Association (ANA) Code of Ethics for Nurses (2010), if the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate within the professional scope of nursing practice.

Arrange these fine-motor skills in ascending order as the infant develops them. 1. Reflexive grasp 2. Looks at and plays with fingers 3. Pulls feet to the mouth 4. Bangs objects together 5. Uses pincer grasp 6. Places objects into containers

They are in correct order The infant begins to develop fine-motor skills within the first month of its birth. The reflexive grasp is seen in the first month. By the age of two to four months, the infant begins to look at his fingers and play with them. The infant is able to bring objects from the hand to the mouth. At four to six months, the infant begins to pull his or her feet to his or her mouth to explore. By the age of six to eight months, the infant is able to hold objects and bang them together. The infant begins to crawl by the age of eight to 10 months and use a pincer grasp to pick up small objects. At this age, the infant also shows a hand preference. The infant is able to pick up objects and place them in containers by the age of 10 to 12 months.