N120- HESI: AQ Practice Quiz - Interventions

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?

"A nurse should provide a personal point of view." Rationale 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.

A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention?

Avoiding focusing on the client's physical symptoms Rationale The physical symptoms are not the client's major problem and therefore should not be the focus of care. This is a psychological problem, and the focus should be in this domain. Encouraging the client to try to walk is focusing on the physical symptom of the conflict; the client is not ready to give up the symptom. The disorder operates on an unconscious level but is very real to the client; saying there is nothing wrong denies feelings. Psychotherapy, not physical therapy, is needed at this time.

Which statement by the nurse is true for collecting a urine sample in toddlers?

Single-use bags can be placed over the child's urethral meatus. Rationale Single-use bags are placed over the child's urethral meatus for collecting urine in toddlers. A potty chair or specimen hat placed under the toilet seat is usually effective in cases of young children. Specimens obtained by squeezing urine from the diaper are not used because the results will be inaccurate. A young child is often reluctant to void in unfamiliar receptacles. They should not be forced to void.

The nurse should understand the effects of internal and external variables to plan and deliver individualized care. Which variable is an example of an external variable?

Socioeconomic factors Rationale Socioeconomic factors are considered to be external variables. Spiritual factors, developmental issues, and the perception of functioning are internal variables.

What does the nurse educate the mother of a toddler to do in order to promote safety?

Throw plastic bags away Rationale The nurse educates the mother of a toddler to remove plastic grocery or other bags from from the house to reduce the risk of suffocation. The nurse should instruct the mother not to fill the crib with stuffed toys as there is an increased risk of suffocation. Putting pacifiers around the neck of the child attached with a string increases the risk of choking. The nurse should tell the mother to place a newborn on his or her back to sleep; it reduces the risk of sudden infant death syndrome.

What is the maximum recommended dose of an intramuscular injection in a preschooler?

1 mL An intramuscular dose is very small and usually does not exceed 1 mL in toddlers or 0.5 mL in infants. The other options, 1.5 mL and 2 mL, are incorrect.

What is the maximum recommended dose of an intramuscular injection in a toddler?

1 mL An intramuscular dose is very small and usually does not exceed 1 mL in toddlers or 0.5 mL in infants. The other options, 1.5 mL and 2 mL, are incorrect.

A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. Which behavior by the client demonstrates an increase in client autonomy?

Active participation in providing self-care Rationale Planning self-care demonstrates decision-making by the client; participating in care enhances feelings of self-worth and autonomy. Expectations do not reflect autonomy. Discussing necessary lifestyle changes with family members does not reflect autonomy; it may be intellectualization. Listing the indicators for recovery after a myocardial infarction does not reflect autonomy; it may be intellectualization.

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client?

Constant one-on-one supervision Rationale A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. Seclusion and four-point restraints are overly restrictive.

A registered nurse is educating a nursing student about descriptive theories. Which point stated by the nursing student needs correction?

Descriptive theories help direct specific nursing activities. Rationale Descriptive theories do not direct specific nursing activities. Instead, they help to explain client assessments. Descriptive theories are the first level of theory development. Descriptive theories explain, relate, and in some situations predict nursing phenomena. Descriptive theories describe phenomena, speculate on why they occur, and describe their consequences.

Which method of drug administration does the nurse state is commonly used in toddlers when the child has poor intravenous (IV) access?

Intraosseous Rationale The intraosseous route is commonly used in toddlers for drug administration in an emergency situation. It is most commonly used in infants and toddlers in whom there is poor access to the intravascular space. Intrathecal administration is often associated with long-term medication administration through surgically implanted catheters. Intraarterial infusions are common in clients who have arterial clots. Chemotherapeutic agents, insulin, and antibiotics are administered via the intraperitoneal route.

A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period?

Keeping the client's respiratory passages patent Rationale A patent airway is always the priority; therefore, removal of secretions is imperative. Offering psychological support is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Monitoring the client's fluid balance is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Providing for a means of communication is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor.

A client undergoes removal of a pituitary tumor through a transsphenoidal approach. What should the nurse implement postoperatively?

Maintain the head of the bed at a 30-degree angle continuously Rationale Maintaining the head of the bed at a 30-degree angle continuously decreases pressure on the sella turcica and promotes venous return, thus limiting cerebral edema. Gentle oral hygiene is performed, excluding brushing of teeth, to prevent trauma to the surgical site. Although deep breathing is encouraged, initially coughing is discouraged to prevent increasing intracranial pressure. There is no need to limit oral fluids because of the presence of nasal packing.

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure?

Maintaining the client in the supine position for several hours Rationale Staying flat may help to prevent spinal fluid leakage and postprocedure headache; this is recommended, even though some people develop a headache despite this precaution. Encouraging the client to ambulate every hour for at least 6 hours may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12 hours. The Trendelenburg position may increase intracranial pressure and is not appropriate. Placing the client in the high-Fowler position immediately after the procedure may predispose to spinal fluid leakage; the client should be kept flat.

A nurse administers intravenous (IV) therapy to the wrong client. What possible legal complications might the nurse face in such situation?

Malpractice Rationale If a nurse administers IV therapy to a wrong client, the nurse may face the charge of malpractice. Assault is any action that places the client or the nurse in fear of a harmful or offensive contact without consent. Battery is any intentional touching without consent. False imprisonment occurs with unjustified restraint of a person without legal warrant.

Which nursing intervention prevents footdrop in a client with osteomyelitis?

Neutral positioning of the foot with the use of a splint Rationale A client with osteomyelitis is at an increased risk for footdrop, which results in an abnormal gait. Neutral positioning of the foot with the use of a splint can reduce the risk of footdrop in the client with osteomyelitis. Elevating the client's foot on pillows can reduce the risk of edema. Asking the client with osteomyelitis to flex the affected extremity can result in flexion contracture. Encouraging the client with osteomyelitis to change positions helps prevent complications associated with immobility and promotes comfort; carefully handle the involved limb and avoid excessive manipulation which may lead to a pathologic fracture.

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response?

Panic Rationale People in a panic may initiate a group panic reaction even in those who appear to be in control. Comatose individuals will not cause panic in others. Euphoric individuals will not adversely affect others. Depressed people will be quiet and not affect others.

Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury?

Performing a jaw thrust maneuver Rationale The jaw thrust maneuver is the recommended procedure for opening the airway of an unconscious client with a possible spinal or neck injury. Needle thoracostomy should be performed in a client with absent breath sounds. Cardiopulmonary resuscitation should be initiated in a client when there is no pulse. Providing oxygen via a nonrebreather mask is mainly performed when the client is conscious.

A student nurse is listing the different aspects of the healthcare services pyramid. Under which type of healthcare services should the student nurse include sports medicine?

Restorative care Rationale The student nurse should include sports medicine under restorative care. It is not categorized as primary, tertiary, or preventive healthcare services.

What nursing intervention does a nurse provide during the initiative versus guilt stage?

Teaching parents about child impulse control Rationale The initiative versus guilt stage is seen in children between ages three to six years. During this stage, the nurse should teach parents about child impulse control and cooperative behaviors for better growth and development of the child. During the identity versus role of confusion stage, the nurse should provide enough information to the adolescents, which allow them to choose the treatment plan. The nurse guides the parents to help their child achieve self-control and willpower during the stage of autonomy versus shame and doubt. The nurse assists ill adults in choosing creative ways to foster their social development during the generativity versus self-absorption and stagnation stage.

A registered nurse is teaching a nursing student about systems theories with a specific reference to Neuman's systems theory. Which statements made by the nursing student post teaching are accurate? Select all that apply.

"Factors that change the environment also affect an open system." "The components are interrelated and share a common purpose to form a whole." "An open system interacts with the environment, with an exchange of information between the system and the environment." Rationale Factors that change the environment also affect an open system. The components are interrelated and share a common purpose to form a whole. An open system such as a human organism or a process such as the nursing process interacts with the environment, exchanging information between the system and the environment. A system is composed of separate components, and there are two types of system, open or closed. Neuman's systems theory defines a total-person model of holism and an open-systems approach.

A registered nurse is teaching a nursing student about the components of the magnet model. What information should the registered nurse provide about exemplary professional practice according to the revised magnet model?

"Strong professional practice is established, and accomplishments of the practice are demonstrated." Rationale Exemplary professional practice is evident when a strong professional practice is established, and accomplishments of the practice are demonstrated. The characteristic of transformational leadership is a vision for the future and the systems and resources to achieve the vision are created by nursing leaders. The characteristic of empirical quality outcomes is that the focus is on structure and processes and demonstration of positive clinical, work force, and client and organizational outcomes. The characteristic of structural empowerment includes structures and processes to provide an innovative environment in which staff are developed and empowered and professional practice flourishes.

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?

"The client considers a change within the next 6 months." Rationale 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.

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F (39° C). The temperature was 99.2° F (37.3° C) when it was taken 6 hours ago. What is a priority nursing intervention in this case?

Administer the prescribed antipyretic and notify the primary health care provider. Rationale Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia then can be initiated. More vigorous intervention than obtaining the respirations, pulse, and blood pressure is rechecking the temperature in 1 hour. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. Assessing the amount and color of urine and obtaining a specimen for a urinalysis is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also, the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. Noting the consistency of respiratory secretions and obtaining a specimen for culture is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma.

What is the priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline?

Administering intramuscular methylergonovine (Methergine) 0.2 mg Rationale A uterus that is displaced and above the fundus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine is administered.

What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein?

Applying arm boards to prevent bending at the elbows Rationale The extremity should be placed in an arm board so the child will not bend the elbow and restrict the flow of IV fluids. First the flow of fluid must be ensured; then the nurse should inspect often for signs of infiltration at the IV insertion site, not the elbow. Pupil responses are unrelated to dehydration and fluid replacement. The parents can be taught how to hold their infant while an IV infusion is being administered.

A client exhibits physical symptoms in response to stress. What nursing intervention may help the client reduce this physiological response to stress?

Assisting the client in developing new coping mechanisms Rationale Until the client learns new ways of coping with stress and anxiety, this pattern of behavior will continue. Learning new ways of coping with stress will help break this physiological pattern. Limiting discussion will avoid the problem. Providing information about medical care will reinforce the sick role. A certain amount of stress is present in everyday family situations; the elimination of stress is impossible.

Which type of play should the nurse encourage when providing age-appropriate care to a preschool-age child who is hospitalized?

Associative Rationale The nurse should encourage the hospitalized preschool-age client to participate in associative play. Team play is appropriate for the school-age child. Parallel play is appropriate for the toddler-age client. Solitary play is appropriate for the infant.

A primary healthcare provider notes that all conventional treatment procedures have proved to be ineffective in managing a client's disorder. The primary healthcare provider decides to try an experimental treatment. The nurse ensures that the client has understood the implications of the new treatment plan thoroughly and then signs the client's consent form as a witness. Which basic healthcare ethic does the nurse follow in this situation?

Autonomy Rationale Autonomy refers to the commitment to include clients in decisions about all aspects of care as a way of acknowledging and protecting their independence. In the given situation, the nurse ensures that the client has thoroughly understood the new treatment plan before gaining written consent. This ensures that the client is involved in the decision-making process appropriately. Justice refers to fairness. The given situation does not deal with fairness. Beneficence refers to taking positive actions to help others. This involves keeping the interests of the client before self-interest. Nonmaleficence is the avoidance of harm or hurt. Weighing the pros and cons of the new treatment plan would involve nonmaleficence.

A nursing student is recalling the definitions of acts that are classified as torts in nursing practice. Which tort involves intentional touching without the client's consent?

Battery Rationale Battery is defined as intentional touching without the client's consent; this action may cause an injury or may be offensive to the client's personal dignity. Invasion of privacy is the announcement of a client's medical information to an unauthorized person. False imprisonment occurs when the nurse places the client in restraints without the approval of the primary healthcare provider. Defamation of character is the publication of false statements that result in damage to a person's reputation.

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates?

Discontinue the infusion. Rationale When an IV infusion infiltrates, it should be removed to prevent edema and pain. Elevation does not change the position of the IV cannula; the infusion must be discontinued. Flushing the tubing will add to the infiltration of fluid. Soaks may be applied, if prescribed, after the IV cannula is removed.

Which domain of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation?

Domain 2 Rationale Domain 2 of the Nursing Interventions Classification taxonomy includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 includes care that supports psychosocial functioning and facilitates life style changes. Domain 4 includes care that supports protection against harm.

According to Piaget during which developmental state is the pediatric client egocentric?

Early childhood Rationale According to Piaget, the early childhood (toddler) and preschool-age child are both egocentric [1][2]. Infancy, adolescence, and middle childhood are not characterized as being egocentric, according to Piaget.

The nurse should understand the effects of internal and external variables to plan and deliver individualized care. Which variable is an internal variable?

Emotional factors Rationale Emotional factors are internal variables. Family practices, cultural background and socioeconomic factors are external variables.

A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with?

Evidence-based practice Rationale The QSEN competency evidence-based practice states that a nurse should integrate best current research with clinical expertise and client's preferences and values in order to provide quality healthcare. Safety involves nursing actions aimed at minimizing the risk of harm to clients and healthcare workers by ensuring system effectiveness and improving individual performance. Quality improvement involves the use of data to monitor outcomes of processes and implementation of methods to improve the healthcare delivery system. Patient-centered care states that the client is the source of control in providing healthcare.

A nursing student is listing examples of active and passive health promotion strategies. Which strategy is an example of a passive health promotion strategy?

Fluoridation of municipal drinking water Rationale 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 client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention?

Focusing on the present Rationale Crisis intervention deals with the here and now; the past is not important except in building on client strengths. The client is anxious and uncomfortable because of the current situation; the focus is on the present, not the past. Psychotherapy is not appropriate for crisis intervention; psychotherapy focuses on the causes of current feelings and behavior and may be provided long term. Exploring the client's history of mental health problems is not significant to crisis intervention.

An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention?

Giving the client one simple direction at a time in a firm, low-pitched voice Rationale Clients who are out of control are seeking control and typically respond to simple directions stated in a firm voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client. Allowing the client to act out until fatigue sets in will not help the client gain control and might be frightening to other clients in the dayroom. Guiding the client from the room by gently holding the client's arm is done only after an attempt at calming the client has failed.

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?

Implementation Rationale 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.

What is the priority nursing intervention for a young infant who has an intravenous (IV) line in place after undergoing abdominal surgery?

Maintaining patency of the intravenous catheter and tubing. Rationale It is imperative that the nurse monitor the IV site and tubing for patency. Signs of obstruction or infiltration must be detected and, if needed, a new means of circulatory access must be obtained quickly. Oral fluids are not administered after abdominal surgery until peristalsis has returned. There is no reason to limit handling the infant as long as the IV site is not disturbed. Parent-infant contact should be encouraged. Although an accurate output record, which includes the number of voidings, is important, maintenance of the IV infusion is the priority.

A nursing student is recalling the definition of Nurse Practice Acts. What do the Nurse Practice Acts do?

Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. Rationale The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help to distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.

Which is an appropriate action for the registered nurse regarding assisted suicide?

Nurses' participation in assisted suicide violates the code of ethics. Rationale According to the ANA, a nurse's participation in assisted suicide will violate their code of ethics. According to the American Association of Colleges of Nursing (AACN) and the International Council of Nurses', the nurse may have an open attitude toward the client's end of life. According to the American Association of Colleges of Nursing (AACN) and the International Council of Nurses', nurses may listen to the client's expressions of fear and to attempt to control the client's pain. According to the Oregon Death with Dignity Act (1994) the primary health care provider in the state of Oregon can participate in assisted suicide only if an individual with terminal disease makes an oral and written request to end his or her life in a humane and dignified manner.

Which points are important when giving practical knowledge to nursing students about preventing complications in the hospital? Select all that apply.

Nursing students cannot be assigned clinical tasks for which they have not been prepared. Nursing students can work as nursing assistants or nurse's aides when not attending classes. Nursing students should tell their instructor immediately after sustaining a needle stick injury. Rationale Nursing students should never be assigned to perform tasks for which they are unprepared. Nursing students can work as nursing assistants or nurse's aides when they are not attending classes or clinical rotations. Students are often encouraged to apply for part time nursing assistant positions while in school to give them additional clinical experience as they prepare for the nursing role. These additional learning opportunities can reduce the risk of client complications. Nursing students should tell their instructor immediately after sustaining a needle stick injury because the instructor can guide them through the process of obtaining the necessary prevention and treatment measures, as well as provide information and emotional support. Nursing students are indeed held accountable for their actions if a client has been harmed. Nursing students may not act as witnesses on consent forms for hospital treatments and procedures because they are not hospital employees.

What is an important nursing intervention in the care of a hospitalized toddler with cystic fibrosis?

Performing postural drainage Rationale Because the mucus glands secrete thick mucoid secretions that accumulate, reducing ciliary action and mucus flow, the nurse should perform postural drainage, which promotes the removal of mucopurulent secretions by means of gravity. Coughing should be encouraged; it helps bring up secretions from the respiratory tract. Although the nurse should encourage activities that are appropriate for the child's physical capacity, the child's energy should be conserved during acute phases of illness. Providing small, frequent feedings is not necessary; the child with cystic fibrosis may eat regular meals at the usual times.

What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?

Placing a tracheostomy unit by the bedside Rationale The priority is a patent airway; the equipment needed to ensure a patent airway must be immediately available. Although padding the rails of the crib is helpful, it is not the priority. Arranging for a quiet, cool room is unnecessary; it may be done if the child has a high fever or a history of febrile seizures. Although it is appropriate to obtain a recliner so a parent may stay, this is not the priority.

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, what should the nurse do?

Protect the client's head from injury. Rationale Rhythmic contraction and relaxation associated with a tonic-clonic seizure can cause repeated banging of the head. Holding extremities firmly is contraindicated because it can cause broken bones. Inserting an airway between the client's teeth is contraindicated because damage to the teeth can occur if force is used to insert an airway. Moving during a seizure can result in physical injuries; the client should be moved after the seizure.

Which step should the nurse follow for the administration of ear drops in children of 4 to 5 years of age?

Pull the auricle up and out. Rationale When administering ear drops to preschoolers, the nurse should pull the auricle up and out. The cotton ball is placed into the outermost part of the ear canal. The toddler is kept in side-lying position for 2 to 3 minutes, and then the prescribed drops are instilled by holding the dropper 1 cm above the ear canal.

What does a nurse understand by the term regulatory law as applied to nursing practice?

Regulatory law reflects the decisions made by administrative bodies such as the State Boards of Nursing. Rationale Regulatory law, also known as administrative law, reflects the decisions made by administrative bodies such as the State Boards of Nursing when they set down the rules and regulations. Civil laws protect the rights of individuals within society and provide for fair treatment in case civil wrongs or violations take place. Nurse Practice Acts are responsible for describing and defining the legal boundaries of the nursing practice within each state. Common law is based on judicial decisions made in courts when individual legal cases are decided.

Which difficulties faced by an adolescent diagnosed with a chronic illness are attributed to normal development? Select all that apply.

Risk taking Rebelliousness Lack of cooperation Hostility toward authority Rationale Risk taking, rebelliousness, lack of cooperation, and hostility toward authority are attributes of normal personal adolescent development. Peer socialization is something that should be encouraged to achieve independence from family.

Which should the nurse encourage for the adolescent client diagnosed with a chronic illness to achieve independence from family?

Socializing with peers Rationale Socialization with peers should be encouraged[1][2] for adolescent clients diagnosed with a chronic illness to achieve independence from family. Use of coping skills helps the adolescent develop a personal identity. Wearing make-up and buying stylish clothes allows the adolescent to learn through abstract thinking.

A 6-year-old child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. What is the most appropriate nursing intervention?

Stopping the bath and replacing the mask Rationale Interrupting the bath and providing humidified air will reduce energy requirements, allow the child to rest, and lessen the demand for oxygen. Although postural drainage loosens secretions in the lungs, it should not be used when the child is in distress. The orthopneic position will not reduce energy and oxygen demands; the healthcare provider should be called if appropriate nursing measures do not relieve the dyspnea. Suctioning is not performed unless respiratory distress is severe; it increases restlessness and energy demands.

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?

Suctioning the airway Rationale Suctioning must be done to minimize the possibility of the aspiration of meconium into the lungs. If the newborn cries before being suctioned, meconium may be aspirated. If the newborn is bagged, any meconium present will be forced into the lungs. If the newborn is positioned in reverse Trendelenburg, meconium may be aspirated.

A client with cancer is undergoing treatment in a hospital. The nurse finds the orders from the primary healthcare provider inappropriate. Clarification from the healthcare provider does not resolve the nurse's doubts. Who should the nurse contact and inform next?

Supervising nurse Rationale The nurse should go to the supervising nurse or follow the established chain of command if he or she finds any discrepancies in the primary healthcare provider's orders. All nurses must act as risk managers, depending upon the situation. The nurse in question should follow the established chain of command to address his or her doubts. A nursing student is still a novice and is too inexperienced to handle such matters. A nurse administrator manages client care and the delivery of specific nursing services within a healthcare agency; a nurse administrator is not the appropriate person to ask for help in solving the problem at hand.

What legal complications might a nurse face for using a restraint without a legal warrant on a client?

The nurse may be charged with false imprisonment. Rationale 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.

A nurse is in the process of conducting research. What action indicates that the nurse is designing the study?

The nurse prepares questionnaires and selects the treatment plans necessary for the study. Rationale The stage of designing the study is when the nurse chooses the instrumentation for conducting the study. In this stage, the nurse prepares questionnaires and selects physiological measures, interviews, and treatments necessary for the study. The first stage of the research process involves identifying of the problem. At this stage the nurse may gather all relevant articles and review literature for the purpose of conducting the research. The stage of conducting the study involves the nurse obtaining approval from the appropriate authorities and enlisting research subjects. The nurse also monitors whether all investigators are following the appropriate study protocol in order to ensure accuracy of the findings.

While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing?

Thoracentesis Rationale A thoracentesis is performed to obtain a specimen of pleural fluid for diagnosis. The client should be positioned upright with elbows on an overbed table with the feet supported. The client should not talk or cough during the procedure because the inserted needle may cause trauma. A lung biopsy or mediastinoscopy may not require the client to be seated upright. No special precautions are needed after performing ventilation-perfusion scan because the gas and isotope transmits radioactivity for only a brief interval.

What is the main focus of community health nursing?

To improve the quality of health in a population Rationale Community health nursing is a nursing practice focusing on the healthcare of individuals, families and groups with a community. Its main focus is to improve the quality of life and health of a population by preserving, protecting, promoting, or maintaining health. The acute and chronic care of an individual or family is provided by community-based nursing. Instead of focusing on institutional care, community-based nursing brings healthcare within the reach of the community. Factors influencing health services such as political process affecting public policies are handled by public health nursing. Community-based nursing focuses on the fulfillment of the healthcare needs of an individual or family.

According to Quality and Safety Education (QSEN), what is patient-centered care?

Understanding that the client is the source of control when providing care Rationale The Quality and Safety Education (QSEN) competency called patient-centered care requires the nurse to understand that the client is the source of control. The nurse should therefore respect the values, beliefs, and preferences of the client to provide quality care. The QSEN competency called teamwork and collaboration states that a nurse should function effectively within nursing and interprofessional teams in order to provide quality care. Quality improvement involves using data to evaluate the outcomes of care processes and design methods to improve the health care delivery system. Safety focuses on minimizing the risk of harm to clients and health care workers through improved professional performance.