NCLEX SET 1

Which of these are examples of primary prevention activities?

An exercise class Car seat installation education Vaccination Engaging in an exercise class, correctly installing a child safety or car seat and getting vaccinations are considered primary prevention activities. Rehabilitation falls under tertiary prevention. Cholesterol screening and breast self-exam are secondary prevention interventions.

The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept?

An older adult client diagnosed with cystitis who has an indwelling urethral catheter. Rationale: LPNs who are reassigned to work on a different unit should be assigned to clients who are stable. The older adult diagnosed with cystitis is the most stable and the outcomes for care are fairly predictable. The other clients have more complex problems, as well as a higher risk for instability. LPNs should not accept an assignment that is beyond their knowledge or skills.

Which of the following interventions should the nurse include in the plan of care for a client who recently experienced a fall at home?

Apply nonslip strips to the bottom surface of the shower. Ensure the room lighting is adequate and remove clutter in the room. Monitor blood pressure when lying down, sitting and standing. The nurse should ensure that the client's home environment is safe (i.e., has appropriate lighting, is free of clutter and unnecessary furniture and throw rugs). There is no indication for an indwelling catheter for this client, and unnecessary urinary catheterization is a risk factor for catheter-associated urinary tract infections (CAUTIs). Chairs with armrests can reduce the risk of falls, since the armrests provide support and help prevent client from sliding off the chair. Monitoring blood pressure for orthostatic hypotension can reduce the risks of falls. Nonslip strips and grab bars can improve safety in the bathroom and reduce the risk of falls.

The nurse is setting up a client's dinner tray. When the nurse turns her back to the client, the client grabs the nurse's buttocks and states he is hungry for much more than dinner. Which of the following responses by the nurse is indicated?

Complete an incident report To keep the therapeutic relationship intact, a nurse needs to set limits on appropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this client.

A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?

Complete and accurate documentation of assessments and interventions The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.

A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first?

Confirm that the client's hearing is intact. A baseline evaluation of a client's neuro-sensory status should include checking for hearing loss. The client's inability to hear may cause them to answer questions incorrectly, which can be misinterpreted by the nurse as short-term memory loss or confusion. The other actions should then also be implemented to further evaluate the client's cognitive and mobility status.

A client is being prepped for a surgical procedure and the nurse is reviewing the consent form with the client. The client asks, "Is there any other way to take care of this without having surgery?" What should the nurse do next?

Notify the surgeon that the client has additional questions about the surgery. rational The client should only sign the consent form after all their questions are answered. Notify the appropriate health care provider if the client needs additional information about the surgery. Once the client has all the necessary information, they can then decide not to sign the informed consent form and the surgery can be cancelled. Offering false reassurance violates the client's right to autonomy. Cancelling the surgery is premature at this time.

A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) who will assist the client to ambulate?

"Have the client lift and move the walker out to arm's length, then walk into the walker." rationale The nurse should give clear and concise information to the UAP about what is expected to safely complete any task, which is why the option about using the walker is correct. The person assisting the client to ambulate should walk on the client's weak, not strong, side. The nurse should not instruct the UAP to assess or evaluate a client (e.g., "let me know if the client uses the quad cane correctly"). Only nurses can perform those steps of the nursing process. If the client feels dizzy, the UAP should assist them to sit (or ease the client to the floor if they begin to fall.)

The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.)

"Have you thought about what you want done as your disease progresses?" "Have you discussed your wishes regarding resuscitation with your health care provider?" Correct! "What does your family know about your condition and prognosis?" Correct! Approximately half of all deaths from heart failure are sudden and without warning. It is important to assist the client and family in planning for the possibility of sudden cardiac death at home. The nurse should discuss advance directives with the family and encourage them to develop a plan of action that addresses the client wishes. Although heart transplants are an option for clients with heart failure, discussions about treatment options (including a transplant) are the responsibility of the health care provider, not the nurse. Asking the client about their current understanding of the disease will help the nurse determine what additional education might be needed. Although it might be helpful for family members to know how to perform CPR, it is not appropriate for the nurse to request CPR certification.

The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase?

Achievement or status of progress related to prior goals Correct Response Evaluation process of the clinical problem-solving process (the nursing process) should focus on the clients' status, progress toward goal achievement and ongoing re-evaluation of the plan of care. LPN/VN's gather, observe, record and communicate client responses to nursing interventions.

During a discussion about a living will, the client's son states, "I do not understand the need for a living will." What is the best response by the nurse?

"Health care decisions can be made based on the client's wishes." rationale Health wishes are written in a legal document such as a living will or advanced directives. These wishes are obtained when clients are medically and cognitively able to do so. Such instructions are to be followed if clients are no longer able to make decisions because of cognitive impairment or unconsciousness. One incorrect response defines a health care surrogate or a durable power of attorney. Another incorrect response defines medical directives and not part of a living will. The final incorrect response is associated with the DNR, which may be predetermined by the client as written in a legal document.

The nurse in a primary care provider's office is collecting data on lifestyle choices and activities of daily living (ADLs) from an older adult client. Which of the following statements by the nurse would be appropriate?

"How do you spend your time on a typical day?" "Tell me what you eat on a typical day." "How many glasses of alcohol do you drink per day or per week?" Data collection on ADLs and lifestyle choices measures a client's ability to provide self-care and maintain their health and should be done in a way that positively reinforces what the client is doing correctly. It also collects general information on the client's overall health status. It should be done in a clear, non-judgmental manner. Asking if someone feels unsafe can be unclear. The nurse should use open-ended questions to obtain as much information as possible.

The nurse is providing education to a client in her first trimester of pregnancy. Which statement indicates the client needs further education?

"I will schedule visits with my health care provider only as needed." A pregnant client must adhere to a strict health care visit protocol. The nurse must provide this information and set up an appointment schedule for the client. Adhering to the appointment schedule with the health care provider can help ensure a healthy pregnancy and can identify and prevent complications.Fatigue is normal for a pregnant client to experience along with other symptoms such as, but not limited to, nausea, frequent urination and breast sensitivity. Pregnant clients should continue to take their prenatal vitamins to help prevent complications and may remain on an exercise schedule as discussed with their health care provider.

A client has received a prescription for nitrofurantoin to treat a urinary tract infection. Which of the following statements made by the client indicates the need for additional teaching about the medication?

"I will spend extra time in the sun to get plenty of vitamin D." Clients taking nitrofurantoin should avoid exposure to sunlight while taking the medication. Exposure to sunlight while taking this medication can lead to damage to the skin. A client planning to spend extra time in the sun while taking nitrofurantoin should be informed of the dangers of sun exposure and counseled to avoid sun exposure while taking the medication.Client statements reflecting the importance of taking the complete course of antibiotics, notifying the health care provider if a rash develops and taking the medication with food demonstrate correct understanding of important considerations while taking this antimicrobial therapy.

How should Michael respond?

"Mr. Evans, thank you for coming and letting me know the situation. I'm sorry your partner has waited so long for someone to help him. I can understand your frustration. The CNA or I will be right over." It is important that the nurse manage the conflict by acknowledging the family member's concern and frustration. Give a timeframe regarding when the client's needs will be addressed (e.g., "a few minutes"). The next steps might involve the nurse offering to help the client and family discuss their concerns with the manager or charge nurse to make sure they feel as though their concerns were addressed appropriately.It is important not to respond defensively or take the family member's comments personally. An aggressive response will only escalate the problem. Using hospital policy as a justification or blaming others will not solve the problem and may contribute to the family member's sense that no one cares about the client.

A woman comes to a clinic to discuss contraceptive options. Which statement by the client indicates to the nurse a need for additional teaching?

"My diaphragm will work no matter how much weight I gain." "If my etonogestrel vaginal ring (NuvaRing) falls out, I still will be protected from a potential pregnancy." "I will return every month for a medroxyprogesterone acetate (Depo-Provera) injection." Women who smoke while taking oral contraceptives have an increased risk for a myocardial infarction, stroke and hypertension, so smoking cessation should be encouraged. Diaphragms should be refitted after pregnancy and pelvic surgery and whenever the client's weight changes. Medroxyprogesterone acetate (Depo-Provera) injections are effective for three months. Cervical caps, sponges and IUDs increase the risk for pelvic infections. Vaginal rings may fall out and alternative contraceptive methods should be used. Abstinence is the only method that provides complete protection from pregnancy.

The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client?

"Please tell me your full name and date of birth." "Do you have any questions about the colonoscopy?" "Describe what the health care provider told you about a colonoscopy." Rationale The nurse first verifies the identity of the client using two identifiers to ensure the correct client is consenting to the procedure. The health care provider is responsible for providing the information necessary for the client to make an informed decision regarding the procedure, including the alternatives. The role of the nurse in the informed consent process includes ensuring the person is understands the procedure and is capable consenting to the procedure. Impediments to informed consent include language barriers, temporary or permanent disorientation, confusion and anxiety. Having the client describe the procedure allows the nurse to determine if the client understands the information they received from the health care provider. The nurse should also watch the client sign the form to ensure it is signed by the client and not by another person.

When walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse?

"Since I am late for lunch, would you perform my client's blood glucose test?" rationale Only registered nurses (RNs) and licensed practical or vocational nurses (LPN/VNs) can assign tasks and activities. UAPs cannot re-assign tasks or activities to other UAPs. Nurses are accountable for all nursing care; if UAPs cannot complete assignments, they should notify the nurse, who will reassign the task.

The parents of a toddler ask, "How long will our child have to sit in a car seat when riding in a car?" What would be the best response by the nurse?

"Until the child outgrows the car seat." The American Academy of Pediatrics (Nov. 2018) provides four evidence-based recommendations for best practices in the choice of a car safety seat (CSS) to optimize safety in passenger vehicles for children from birth through adolescence: Use rear-facing car safety seats for as long as the child fits in the seat. Most children should use forward-facing car safety seats from the time the child outgrows rear-facing seats until at least age 4. Most children should use belt-positioning booster seats from the time the child outgrows forward-facing seats until age 8. Use lap and shoulder seat belts for all children who have outgrown booster seats.

A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client's health care provider?

"When I emptied my urine catheter drainage bag it looked like rusty-colored water." The change in the color of urine to "rusty" suggests blood, a potential sign of an infection or other urinary-renal complication. This requires immediate reporting, documentation and further assessment. The other statements do not require immediate interventions, but should also be addressed as they could indicate depression, social isolation or an underlying, undiagnosed physical problem.

The nurse is preparing to administer regular insulin subcutaneously to a client at 0800. What information from the client's electronic health record should the nurse review in order to safely administer the medication? (Select all that apply.)

1. Name and date of birth. 2. 0700 blood glucose. 3.Medication administration record (MAR). The nurse must review the appropriate information in order to safely administer medications. The use of two client identifiers is to ensure the identity of the correct client. The nurse must review the medication administration record (MAR) to verify the correct medication, dose, and time. The nurse should review the client's most recent blood sugar value before administering the insulin to prevent hypoglycemia.

The automated external defibrillator (AED) has been applied to a client receiving cardiopulmonary resuscitation (CPR). Indicate how the nurse will proceed by placing the following actions in the correct order.

1. Press the analyze button when the AED prompts the nurse to do so. 2. Wait for the AED to analyze the client's heart rhythm. 3. Call out a ''stand clear'' when the AED prompts the nurse to administer a shock. 4. Press the shock button on the AED. 5. Allow for time on the AED to administer a shock. 6. Immediately resume CPR. The American Heath Association (AHA) guidelines for CPR recommend rapid CPR implementation including use of an AED. AEDs provide early interpretation of the client's cardiac rhythm. It provides step-by-step instructions on how to proceed with defibrillation if indicated.

The hospital is under a severe weather warning. The nurse is prioritizing clients for discharge to make beds available for possible emergency admissions. Which of the following adult clients would be most appropriate to discharge?

A client who is ambulatory with the support of crutches. A client who can manage their self-care. A client who requires the administration of enoxaparin. In preparing for a weather emergency, it may be necessary to discharge clients to ensure hospital beds are available for emergency admissions. Ambulatory clients who can manage their self-care should be discharged first. Those requiring minimal care can also be considered for discharge. Clients with complex dressing changes, or who require mechanical ventilation cannot be considered for discharge. Clients or family members can be taught how to self-administer subcutaneous medications such as the anticoagulant enoxaparin (Lovenox) at home.

The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy?

Accepting physical changes related to pregnancy. During the first trimester, the developmental focus is directed toward accepting the pregnancy and adjusting to pregnancy-related physical changes and discomforts. It is expected that the client will have some ambivalence during the first trimester, but the client can maintain physical intimacy with her partner if she wishes, including sexual intercourse. Looking at the fetus as a separate being and overcoming fears related to giving birth will occur in the third trimester, closer to the due date.

The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase?

Achievement or status of progress related to prior goals rationalEvaluation process of the clinical problem-solving process (the nursing process) should focus on the clients' status, progress toward goal achievement and ongoing re-evaluation of the plan of care. LPN/VN's gather, observe, record and communicate client responses to nursing interventions.

The nurse understands that which situations require hand hygiene such as handwashing or hand sanitation?

After contact with objects in the immediate vicinity of the client Before having direct contact with a client After cleaning a wound Prior to and after eating Handwashing is still the simplest and most effective strategy to prevent the spread of infection. It is necessary to wash one's hands to protect oneself prior to eating, after removing gloves following any client procedure and even after having contact with intact skin or objects in the client's room. However, it is not necessary to wash hands after handling every chart (although using an alcohol-based hand rub would be advisable).

A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client?

All clients have a right to be informed about their prescribed medications Clients have the right to be informed about the use and side effects of their medications, regardless of their diagnosis. Clients have the right to refuse treatment, including taking prescribed medications, even if the client has a psychiatric diagnosis such as schizophrenia.

The nurse is interviewing a client to verify pregnancy. What information from the client will provide presumptive findings?

Amenorrhea Breast sensitivity Nausea A client typically will report breast sensitivity, missed period, nausea and fatigue (this is not a complete list of symptoms pregnant women could report). Uterine and/or cervical changes cannot be reported by the client but will be a finding of the health care provider.

A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)?

Assist with transferring the client from the bed to the chair. The CNA (i.e., UAP) can assist with routine activities of daily living, including transferring clients from a bed to a chair or wheelchair. When performed correctly, these routine tasks usually have a predictable outcome. Checking the client's skin involves assessment and monitoring the client's response requires evaluation, both of which are nurse-only activities. A physical therapist would teach the client how to ambulate with an orthotic

During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next?

Auscultate the area. A pulsating mass at the periumbilical area is indicative of an abdominal aortic aneurysm (AAA). Auscultation of the abdomen should be done next to check for a bruit, which will further confirm the possible presence of an AAA. The other actions are contraindicated because causing pressure to the area through palpation or percussion may cause the aneurysm to leak or rupture. Measuring the area would not provide any useful data.

The nurse is reviewing the client's medical record and notes that the client has been taking an oral contraceptive for several years. For which potential complications should the nurse monitor the client?

Breast cancer Deep Vein Thrombosis (DVT) Depression Oral contraceptives contain both advantages and disadvantages for clients. Advantages include shortening menstrual cycles, decreasing anemia and protecting against bone loss. Clients have decreased risks for ovarian, colorectal and endometrial cancers. Potential complications include increased risks for breast cancer, depression and a DVT. Women who smoke may have an increased risk for myocardial infarction, stroke and hypertension.

A client's family member calls for an update on the client's condition. What should the nurse do first before providing information to the caller?

Check with the client and obtain permission to provide the caller with the requested information. rational The nurse must have permission from the client to release information to the caller. If the client is unable to give permission and has a power of attorney for health care (POAH), then information shall only be given to the POAH. Family members can obtain updates from that person. Remember, it is difficult to know who is calling over the phone. The nurse should also be familiar with the organization's policy on requests for information over the phone.

The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next?

Close all doors in the area. The nurse should act immediately to protect the clients under their care. This begins with closing all doors to prevent the fire from spreading. It is not necessary to evacuate the clients because they are not in immediate danger. The fire extinguisher is not needed since there is no active fire in this area. Removing oxygen devices is not required.

A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client?

Color of bowel movements Frequency and amount of naproxen used Bruising Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen can cause gastrointestinal (GI) irritation and bleeding. The client's vital signs and pale skin color indicate possible hypovolemia (tachycardia and hypotension) secondary to blood loss. The nurse should inquire about other findings that may indicate bleeding, e.g., black tarry stools and bruising. The nurse should also determine the amount of naproxen the client has been taking. Tingling, numbness or photophobia are not side effects seen with naproxen use or overuse.

A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse?

Explore for further identification about the nature of the problem Helping staff manage conflict is part of the charge nurse's role. It is appropriate to work with the LPN in order to work out problems with minimal intervention from administration when possible. Further definition of the problem and associated issues would be a first step. The nursing process can be used to collect more data before plans or interventions are made.

The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed. What action should the nurse take first?

Immediately wash hands vigorously with soap and warm water. The immediate action of vigorously washing the hands will help reduce the risk of potential exposure to bloodborne pathogens. The nurse should then follow the facility's policy and procedure for employee needlestick injury.

A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take?

Discuss with the client to find out about the preferred herbal preparation Remember, the collection of additional data is typically the initial approach when problems arise. Although the client has the right to refuse the medication, it's possible that the herbal preparation does not have the intended purpose of the prescribed medication or may even have unintended side effects.

The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include?

Empty the child's mouth of any poisonous substance still present. Emptying the mouth of the poison prevents any further ingestion. It should be done first to minimize further contact with and absorption of the substance. The parent should call the Poison Control Center before giving any treatment. Never induce vomiting unless instructed to do so by the Poison Control Center or a health care provider. The same applies for giving the child milk to drink because not all poisons are neutralized that way.

The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse?

Encourage the UAP to directly confront the HCP about the unprofessional behavior. The QSEN competency Teamwork and Collaboration requires the nurse to function effectively within nursing, working with inter-professional teams, and fostering open communication and mutual respect. The nurse should first approach the HCP to stop the behavior and then attempt to discuss communication styles that diminish the risks associated with authority gradients among team members. Notifying the chief of the medical staff might be necessary in the future if the HCP continues to act unprofessionally toward the staff. Directly confronting the HCP would most likely cause the HCP to become defensive and should be avoided. Completing an incident report is not necessary at this time. Correct!

The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse?

Encourage the UAP to directly confront the HCP about the unprofessional behavior. rational The QSEN competency Teamwork and Collaboration requires the nurse to function effectively within nursing, working with inter-professional teams, and fostering open communication and mutual respect. The nurse should first approach the HCP to stop the behavior and then attempt to discuss communication styles that diminish the risks associated with authority gradients among team members. Notifying the chief of the medical staff might be necessary in the future if the HCP continues to act unprofessionally toward the staff. Directly confronting the HCP would most likely cause the HCP to become defensive and should be avoided. Completing an incident report is not necessary at this time.

The parent of a 7-year-old child calls the clinic nurse because their child was sent home from school due to a rash. The child was diagnosed with fifth disease (erythema infectiosum) the day before and is otherwise in good health. What would be the appropriate action by the nurse?

Explain that the rash is no longer contagious and does not require isolation. Fifth disease is a viral illness with an uncertain period of communicability (perhaps one week prior to and one week after the onset). Children are not contagious after the appearance of the rash, which gives a "slapped cheek" appearance. Isolation of children with fifth disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the health care provider to give to the school. Treatment is symptomatic and supportive. Antibiotics are not indicated for this viral infection.

The nurse observes another nurse walking away from their computer with a client's electronic medical record (EMR) still visible on the screen. What should the nurse do first?

Walk over to the computer and close the client's medical record. rational All of the nurse's actions are appropriate, but in order to prevent unauthorized personnel from seeing any of the client's protected health information, the nurse should first close the client's EMR, which is still visible on the screen.

A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client?

Face the client while asking questions as the interpreter translates the information rationale: Communication is important, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, the nurse should face the client and allow the interpreter to translate the content. Facing the client allows nonverbal communication to take place between the client and nurse. Notice that only one option includes the content of this question (collecting data from a client). The other options focus on the "interpreter or the family." Usually, the client-centered option is the best choice.

The clinic nurse is meeting with a client who wants to talk about her and her partner's plan for a future pregnancy. What information is important for the nurse to give to the client?

Folic acid should be started before the client has a confirmed pregnancy. Women should start to take folic acid prior to pregnancy to decrease the risk of neural tube defects. Preconception care involves a complete review of both partners' medical history. Medications, supplements, nutrition and psychosocial concerns should be reviewed. Risk factors which impact pregnancy, such as alcohol, drug use, medications, infections, etc., should be identified and avoided. Immunizations should be reviewed and encouraged before pregnancy.

A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client's health needs?

Identify the client's learning needs. With a focus on health promotion, the nurse should first identify any learning needs. This also represents the first step in the nursing process. Once the client's learning needs are identified, the nurse will be able to develop or assist with developing a plan of care that meets the client's individual needs. Then the nurse should perform a home safety check, identify community resources for the client and, if needed, assist with meal planning.

The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take?

Hold the medication and contact the health care provider. LPN/VNs cannot administer medications using intravenous push or bolus route. The nurse will need to contact the health care provider and ask to have the order changed so the medication can be administered by another route.

The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take?

Hold the medication and contact the health care provider. rational LPN/VNs cannot administer medications using intravenous push or bolus route. The nurse will need to contact the health care provider and ask to have the order changed so the medication can be administered by another route.

The nurse is handing-off the care of a client admitted with pneumonia to the nurse for the next shift. What client information should the nurse include in the hand-off report, using the S.B.A.R. method?

IV access, admitting diagnosis, allergies and antibiotics given rational S.B.A.R. stands for situation, background, assessment and recommendation. Situation in the model refers to the client's main problem. Background refers to the client's basic information, such as admitting diagnosis, allergies, etc. Assessment refers to objective and subjective data the nurse collects that helps to define the client's problem. Recommendation is the nurse's suggested solution(s) to the problem. Insurance information, marital status and religious affiliation are not shared when using the S.B.A.R. model of communication.

A child is admitted with a suspected diagnosis of meningococcal meningitis. Which admission order should the nurse implement first?

Implement droplet precautions. Meningococcal meningitis is a contagious infection caused by the bacteria Neisseria meningitis. The first action the nurse should take is to implement droplet precautions to prevent transmission of meningitis. Then the nurse will focus on the therapeutic management of acute bacterial meningitis which includes anti-infective therapy (a cephalosporin or penicillin) and monitoring of the client's neurological status along with vital signs. The nurse should institute seizure precautions and maintain adequate hydration of the client.

The nurse is reviewing information about the health care organization's efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting?

Improve the quality of care in a proactive manner. Rationale: Continuous quality improvement (CQI) is used to identify ways to correctly do the right thing at the right time. It involves proactive problem-solving. Proactive means implementing steps to prevent something from happening rather than responding to it after it has happened (being reactive). The overall goal of CQI is to improve the quality and safety of health care services.

Upon completing a review of a 27-year-old client's admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take?

Inform the charge nurse to offer information about advance directives. For every admission, the nurse should check if the client has advance directives and if yes, that a copy of the current advance directive is in the medical record. If there are none, the nurse should inform the appropriate interdisciplinary team member to provide information to the client. In most health care settings, nurses, social services, case managers or the spiritual support team can educate clients on advance directives, including helping them complete an advance directive. Every adult client should have advance directives. The client is 27-years-old and is therefore considered an adult.

The nurse recognizes that client identification in accordance with agency policy must occur immediately prior to which of the following actions?

Insertion of an indwelling urinary catheter Administration of oral acetaminophen Discontinuation of an intravenous normal saline infusion Collection of a point of care blood glucose test As part of safe nursing care, the nurse must collect client identification with at least two approved identifiers according to agency policy immediately prior to medication administration, implementation of health care provider prescriptions, collection of laboratory samples, discontinuation of intravenous infusions and many additional situations. It would not be required to confirm the client's identification immediately prior to placing the call light activation device within reach.

The nurse observes a nursing assistant using antiseptic hand sanitizer and rubbing their hands vigorously after leaving the room of a client diagnosed with Clostridium difficile (C-Diff). Which action by the nurse is appropriate?

Instruct the nursing assistant to wash their hands again with soap and water. Anyone who is hospitalized should be encouraged to ask caregivers if they washed their hands and to remind visitors to wash their hands. However, it is the nurse's responsibility to supervise the nurse assistant and to correct practice errors as needed. C. diff is one of the few pathogens that require soap and water for cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by this bacterium, the nurse should require the nursing assistant to wash their hands with soap and water, especially after providing care for this client.

The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure?

Involve the client in making decisions. Although all these interventions may benefit the client, the involvement of the client in making health care decisions is the most important intervention to improve meeting desired goals and outcomes. The client will be more motivated to adhere to the nurse's recommendations if they are involved in the process of setting priorities and making decisions.

A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan?

Keep a time log for what was done during the hours worked The first step in planning for time management is to establish what tasks were done and when they were completed. This provides a baseline for needed changes in any activities and time use log. The key words in this question are "time management," "most effective," and "initial development." Remember the first step in the nursing process is data collection - this applies to both caring for clients and developing management skills. Correct!

The nurse is reviewing the documentation of a client's care in their electronic health record and realizes that one of the entries was completed on the wrong client. Which of the following actions are appropriate for the nurse to take?

Mark the entry as "mistaken entry-wrong patient." Enter the time the error was discovered. The entry should be identified as being a mistake. Records should not be deleted. It is not necessary to notify the health care provider, complete an incident report or notify the nurse manager as long as the nurse follows the appropriate policy for correcting documentation errors. The nurse needs to enter the time the error was discovered in order to have a record of the change.

The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)?

Measure blood pressure, pulse and respirations rationale UAP can perform standard tasks with predictable outcomes, such as measuring vital signs. They are trained to assist the client with activities of daily living. UAPs cannot assess, plan, teach or evaluate clients

The client requests not to be interrupted before 10 am because it interferes with the client's time to meditate. What action shall the nurse take first?

Meet with the client to formulate a mutually agreeable schedule. rationale The nurse should communicate with the client to help determine how their meditation practice can be incorporated into the morning schedule. This is the first step in the nursing process and will help the nurse develop an individualized plan of care that incorporates respect for the client's personal choices and preferences.

The nurse is caring for a patient who has just experienced a spontaneous abortion (miscarriage). What action should the nurse implement first?

Monitor the client for bleeding and medicate for pain The nurse's priority is to address the client's physical needs (A-B-C) according to Maslow's hierarchy of needs. The nurse must assess and monitor bleeding and be prepared to act if there is a complication such as a hemorrhage. The other actions are also part of the nurse's plan/implementation but are not the initial priority.

The nurse observes two unlicensed assistive personnel (UAPs) transferring a client using a mechanical lift. Which observations would require the nurse to intervene immediately?

No support is provided for the client's head The client is lowered as quickly as possible to the chair. The safe use of a mechanical lift includes ensuring the equipment and sling are fully functional, and confirming the appropriate weight limit prior to use. The client should be raised just enough to clear their bottom off of the bed. The client should be lowered slowly to the chair. The nursing staff will need to provide support for the client's head during the lift.

The nurse hears a scream coming from a client's room. When entering the room, the nurse finds the client lying on the floor beside the bed. Which of the following actions should the nurse take?

Observe the client for abnormal leg rotation. Notify the client's provider about the incident. Take the client's vital signs. Determine the client's level of consciousness. Fall prevention is a national patient safety goal and is monitored closely in all health care settings. It is important for the nurse to assess and evaluate the client to determine if the client experienced a loss of consciousness or a change in vital signs that contributed to the fall. It is important to determine if there are visible injuries and note any areas of pain or abnormal leg rotation. The nurse will notify the provider and complete an incident report. Risk management will receive notification through the completion of an incident report; the nurse should not notify the legal department by themselves. Physical restraints are not indicated and may, in fact, make the client more prone for future falls.

The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person?

Occupational therapist Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work. A physical therapist works with general movement problems, mobility stability, range of motion and/or strength training exercises. It would not be appropriate to refer the client to chiropractor and a pharmacist in this situation.

A newly admitted client has a skin ulcer that tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions should the nurse take when caring for this client?

Place personal protective equipment (PPE) at the door to the room. Place the client in a private room. Keep all equipment in the client's room for their sole use. Perform hand hygiene after contact with the client and before leaving the room. Contact precautions are recommended in acute care settings for MRSA when there is a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and their environment and before leaving the isolation room. Contact precautions require health care workers to wear PPE such as gloves and a gown, which should be readily available. It is not required to keep the door closed at all times.

The nurse is attending an in-service about health care-acquired infections (HAIs). Which factor is considered a common cause of HAIs for clients in the acute care hospital setting?

Presence of an indwelling urinary catheter Catheter-associated urinary tract infections (CAUTI) is one of the more common HAIs in the acute care hospital setting. Surgical site infections, bloodstream infections and pneumonia are other types of HAIs, but are less common than CAUTIs.

Which of these activities can the nurse assign to an unlicensed assistive person (UAP)?

Provide basic care to the client. rationale UAPs' limited scope includes (but may not be limited to) assisting with ADLs such as bathing, feeding, toileting, obtaining vital signs, input and output (I/O), performing point of care (POC) tests, such as a blood sugar check or 12-lead electrocardiogram, and recording height and weight. UAPs cannot reinforce teaching, create a plan of care or assume nursing care for a client - even if the client is stable.

Which action shall the nurse take to preserve the client's right to autonomy?

Providing the client with requested information to make an informed decision. Autonomy can be defined as the personal freedom and the right of competent people to make choices. Autonomy, the principle of respect for a person, is sometimes called the primary moral principle. This concept holds that humans have incalculable worth or moral dignity not possessed by other objects or creatures. If an autonomous person's actions do not infringe on the autonomous actions of others, that person should be free to decide whatever they wish. This freedom should be applied even if the decision creates risk to their health and even if the decision seems unwise to others. Concepts of freedom and informed consent are grounded in the principle of autonomy.

Which of the following defines the Quality and Safety Education for Nurses (QSEN) competency of Patient-Centered Care?

Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. The definition of the Quality and Safety Education for Nurses (QSEN) competency of Patient-Centered Care is: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. The other answers pertain to the competencies of Teamwork and Collaboration, Evidence-Based Practice (EBP) and Quality Improvement.

The new graduate nurse understands that patient-centered care, according to QSEN should include which of the following nursing actions? (Select all that apply.)

Recognizing the boundaries of therapeutic relationships. 2.Respecting and encouraging individual expression of client values. 3.Communicating what care was provided and is needed at each transition in care. rational The QSEN project defines the knowledge, skills and attitudes for six key areas or required competencies for new nurses. Designing systems that support effective teamwork fits under the Teamwork and Collaboration category. Adherence to IRB guidelines is found under the Evidence-based Practice (EBP) competency.

The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)?

Record and report the client's intake and output. The nurse is always responsible for any type of physical, social, emotional or environmental assessment. The nurse must assess the client for edema and also any learning needs the client may have. Furthermore, the nurse would also need to assess the status of an IV site for complications such as infiltration or phlebitis. The UAP is able to assist in direct client care activities such as bathing, ambulating, feeding, obtaining vital signs and recording intake and output.

The nurse notices flames and smoke in the garbage can in a client's room. Which action should the nurse take first?

Remove the client from the area. The nurse's first action in an active fire should be to remove the client from imminent harm. The other actions should occur after the client is taken to safety.

The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take?

Report this request immediately to the nurse manager. rational The incident must be reported to the appropriate supervisor, either the charge nurse or the nurse manager, for both ethical and legal reasons. This is not an incident that a nurse can resolve without referring to an appropriate authority. The second nurse should only sign as a witness to the wasting of a controlled substance if the nurse actually observed the wasting. Signing as a witness without having actually witnessed the wasting action can be considered falsification of records and result in disciplinary action by the nurse's employer and the state board of nursing

The nurse is caring for a client with bilateral wrist restraints. Which intervention(s) should the nurse include in the client's plan of care?

Routinely assess if the client is ready for restraint discontinuation. Monitor the client's emotional response to the restraints. Remove restraints every two hours to allow for movement of involved extremity. Ongoing assessment of clients who require restraints is essential. Restraints should be removed every two hours to allow the nurse to assess the neurovascular status of the restrained extremity, skin integrity under and around the restraint, the client's response to the restraint and the client's emotional state. A new restraint order must be obtained every 24 hours. Assessment of the client with restraints should be documented in the client's medical record at least every 2 to 4 hours. Nurses should frequently assess clients to determine readiness for restraint discontinuation. Restraints should remain in place when client has visitors to ensure client and visitor safety.

The nurse is preparing to ambulate a client who requires the use of a gait belt. Which of the following actions are appropriate for the nurse to take?

Secure the gait belt to fit around the client's waist. Use an underhand grasp at the center of the client's back to grasp the gait belt. When ambulating a client who requires minimal assistance, a gait belt is important to help support the client's mobility. The gait belt should be secured around the client's waist. The nurse should use the inside arm with an underhand grasp in the center of the client's back to secure the belt providing support for the client. With minimal assistance, the nurse should ambulate at the client's pace and support the client's weaker side. The buckle should be in the front of the client.

A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client's dinner. What action should the nurse take next?

Serve the dinner in the seclusion room, maintaining observation Seclusion is ordered by a physician and requires continuous observation, unless the order is discontinued or amended. It is incorrect to amend the seclusion or mealtime. Meals can be eaten in the seclusion room with the nurse continuing the 1:1 observation. Meals must be offered on time and should not be withheld. Contracts for safe behavior are meaningless in the presence of psychotic behavior (mania).

During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform?

Sits without support The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months.

The nurse is discussing modifiable cardiac risk factors with a group of adult clients at a community center. Which topic should the nurse reinforce as the highest priority intervention?

Smoking cessation Stopping smoking is the highest priority for clients at risk for cardiac disease because of the effects of smoking on the arteries, including atherosclerosis and vasoconstriction. The other interventions are also important, modifiable actions to prevent cardiovascular disease (CVD). However, smoking tobacco products is widely considered the greatest risk factor for developing CVD (as well as other diseases).

A client's wound has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which transmission-based precautions should the nurse implement for the client?

Standard precaution and contact precautions Standard precautions are used for all clients, regardless of their diagnosis or presumed infection status. Transmission-based precautions provide additional precautions beyond standard precautions to prevent transmissions of pathogens. Contact precautions are used for infections such as MRSA that spread by skin-to-skin contact or contact with other surfaces.

Where can the nurse find the most reliable guidelines regarding the appropriate delegation of tasks to unlicensed assistive personnel (UAP)?

That state's nurse practice act (NPA). rationale When questions arise regarding who can delegate what activities to which unlicensed provider groups, it is the nurse practice acts (NPAs) of individual states that establish the legal definitions of appropriate delegation practices. Because regulations differ among states, each nurse must identify and understand the regulations for the state in which they practice.

The nurse observes an unlicensed assistive personnel (UAP) about to take a client's temperature with a tympanic thermometer. Which observation would require the nurse to intervene immediately?

The UAP applies lubricant to the thermometer probe. The UAP uses the client's room number and name to identify client. The UAP cleans the thermometer by running it under hot water. The correct procedure for using a tympanic thermometer includes cleaning it with approved anti-bacterial wipes. Lubricant is never applied to the probe and put in the client's ear canal. Using the client's room number as a client identifier is not considered a best practice; the client's date of birth and full first and last name are acceptable.Hand hygiene should be performed before and after using any equipment. It is not possible to use a tympanic thermometer with a hearing aid in place.

The nurse and UAP are preparing to reposition a client in bed. Which of the following actions indicate that the UAP requires additional training on correct body mechanics?

The UAP lifts the client, using their upper arm and shoulder strength. It is important to use proper body mechanics when transferring, lifting or repositioning clients. To apply proper mechanics, the health care worker should stand with their feet shoulder width apart and their knees slightly bent and avoid twisting when repositioning the client. Elevate the bed so the working surface is at waist level, which is the health care worker's center of gravity. The nurse or UAP should bend from the knees to aid in the lift, rather than using their arms and shoulders to reposition the client.

A client with Parkinson's disease is prescribed benztropine (Cogentin). For which of the following should the nurse call the health care provider immediately?

The client has a history of primary angle-closure glaucoma. rational The nurse must be able to recognize adverse drug effects and contraindications of medications commonly prescribed for the client with Parkinson's disease. Common clinical manifestations of Parkinson's disease include bradykinesia (slow movement), dysarthria (slurred speech) and orthostatic hypotension, caused by the loss of the neurotransmitter dopamine. The goal of pharmacotherapy is to restore the functional balance of dopamine and acetylcholine. This is achieved by giving dopaminergic drugs and cholinergic blockers.Benztropine is an anticholinergic medication used in the treatment of Parkinson's disease that blocks excess cholinergic stimulation in the brain and reduces muscular tremors and rigidity. Tachycardia is a potential adverse drug event, but a heart rate increase of 15 bpm is within acceptable limits. Due to their blocking actions of the parasympathetic nervous system, anticholinergics are contraindicated with glaucoma, where they can cause an increase in intraocular pressure (IOP), which can lead to vision loss and blindness.

The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client with a diagnosis of schizophrenia. Which of the following behaviors justify use of this chemical restraint?

The client is experiencing command hallucinations. The client is verbalizing a plan to harm another client. The client is expressing paranoid delusions. Command hallucinations and paranoid delusions can be frightening or dangerous, potentially causing a client to act aggressively. It is important to intervene before a client acts on a plan to harm another person. An antipsychotic medication, such as haloperidol, will help control and manage symptoms and behaviors associated with schizophrenia. A chemical restraint should be used in an extreme or emergent situation. A client has the right to refuse to participate in activities. Verbal intervention, such as offering to speak with the client 1:1, would be appropriate if the client is upset and crying.

The nurse is caring for an 80-year-old client who requires wrist restraints. What client behaviors would support the need to continue to use restraints?

The client is resisting care and attempting to hit the staff. The client is confused and trying to pull out an IV catheter. Physical restraints should only be used as a last resort. If restraints are indicated, the least restrictive device available should be used to restrain the client. The restraint should protect the individual, but also allow for freedom of movement. Circumstances that require the use of physical restraints include when clients attempt to remove life-support equipment, when clients interfere with therapy or treatment (e.g., enteral feedings, intravenous infusions, tracheostomy tubes, etc.) and when clients are combative and a risk to others. Restraints are not indicated for the convenience of hospital staff. Examples of physical restraints include hand mitts, arm sleeves, lap belts and limb restraints.

The nurse enters the room while a student nurse is taking a manual blood pressure on a client sitting in the chair. For which of the following observations should the nurse reinforce teaching with the student nurse?

The client is talking on the telephone and laughing The client is crossing his legs The client is drinking a cup of black tea The air is released rapidly while auscultating for Korotkoff sounds Systolic and diastolic blood pressure increase when talking. If the artery is below heart level, you may get a false-high reading. Caffeine can increase blood pressure if ingested up to 30 minutes prior to taking the reading. The client should not be crossing his legs during BP measurement as that can artificially increase the blood pressure.The air should be released gradually/slowly while auscultating for sound. The cuff positioned at 2 to 3 cm above the antecubital fossa is correct.

The nurse has been assigned to four clients. Which client should the nurse see first?

The client with a history of coronary artery disease (CAD) reporting dyspnea, nausea and unusual discomfort in the upper back rationale Dyspnea, nausea and unusual discomfort in the upper back can suggest an acute myocardial infarction (AMI) and therefore this client should be seen first. The client with the elevated BP should be seen next. Increased urinary output is an expected finding after taking a diuretic and intermittent claudication is a common and expected finding in PAD.

Four clients are admitted to an adult medical unit on the same shift. The nurse should implement airborne precautions for which client?

The client with a productive cough who just returned from vacation in India India has the greatest incidence of tuberculosis (TB) in the world and a client who develops a cough after spending time in India should be tested for TB or other contagious respiratory infections. Until the testing is complete, the client should be placed in airborne transmission-based precautions, which require a private, negative-pressure room. Health care workers would have to use a N-95 mask when in the room providing care for the client. The CMV virus is not highly contagious, but it can be transmitted by close, direct contact with infectious body fluids. Contact transmission-based precautions might be indicated. Clients with VAP and lung cancer are not considered contagious and do not require airborne precautions.

The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? pt. 2

The client with peptic ulcer disease who has been vomiting most of the night A client with a peptic ulcer who has been vomiting a lot might be experiencing perforation of the ulcer, which is a life-threatening situation that requires emergency surgery. The client with the peptic ulcer should be checked first and findings reported to the charge nurse and/or health care provider.

The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report?

The client with peptic ulcer disease who has been vomiting most of the night rational A client with a peptic ulcer who has been vomiting a lot might be experiencing perforation of the ulcer, which is a life-threatening situation that requires emergency surgery. The client with the peptic ulcer should be checked first and findings reported to the charge nurse and/or health care provider.

During the management of a client's pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client's pain?

The client's self-report of pain is the most important consideration. .Pain is a complex phenomenon that is perceived differently by each individual. A client's self-reported pain serves as the foundation for the nurse's approach to pain management. The nurse shall keep in mind that pain is subjective and accept the client's report of pain in a nonjudgmental and objective manner. Client-centered and ethical nursing care requires that the nurse recognizes their personally held values and beliefs about the management of pain and that the client's expectations, values and beliefs influence outcomes in the management of their pain. Correct! LESSON Management of Care or Coordinated Care Ethical Practice COURSE RN & PN Review KEYWORDS code of ethicspatient-centeredclient-centeredpain management CONFIDENCE Need Help Fair Strong

A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints?

The client's status is documented every 15 minutes. The appropriate client advocate or relative has been notified. The radial and pedal pulses are palpable and strong. To avoid injury, restraints should never be fastened to a moving part of a bed or stretcher. A physical restraint order is never "as needed." An order must be written by a provider for each restraint episode. Using profanity and cursing is not cause for physical restraints. To justify physical restraints, the client must be an imminent threat to themselves or others. Strong radial and pedal pulses indicate that the restraints are not occluding circulation. Documentation must be done every 15 minutes on the restraint flow sheet, which is part of the client's permanent medical record. It is a legal requirement to notify the client's advocate or a relative if requested by the client.

While working a 12-hour night shift, the nurse has a "near miss" and catches an error before administering a new medication to the client. Which factors could have contributed to the near miss?

The nurse has worked four 12-hour night shifts in a row The nurse was interrupted when preparing the medication The nurse is assigned more clients than usual due to staffing issues The nurse works in the intensive care unit (ICU) There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients such as the ICU.

The nurse is collecting baseline data on a 14-month-old child during a wellness visit in the primary care provider's office. Which of the following measurement methods are correct?

The nurse measures the child's chest circumference by placing the measurement tape around their chest at the nipple line. The nurse places the tape measure around the child's head at the widest part of the frontal and occipital bones. The nurse places the child on an infant platform scale in either a sitting or supine position. Data collection methods should be correct for the age of the client. Data collection methods for children under the age of two are different than those for older children. A healthy 14-month-old child who is developing normally may prefer to sit on the scale than to be laid on the scale but their height should still be measured while laying down. A toddler's head and chest circumference are measured with a tape measure. The head circumference is measured at the widest point of the frontal and occipital bones, while the chest circumference is measured at the nipple line. An infant or toddler's pulse is counted apically, not radially.

The nurse is preparing to enter a disaster scene to assist with triaging victims. What assessment priorities should the nurse adhere to?

The nurse will allocate resources to those victims with the strongest probability of survival. The nurse will assess clients by considering their airway, breathing, circulation and neurological function. The goal of disaster triage is to use resources for clients with the strongest probability of survival. Age is not a consideration when allocating treatment resources and the nurse does not need to consult a physician prior to making decisions about allocating resources. Furthermore, a nurse does not need special training to assist in a disaster. However, there are certifications available for nurses who are interested. Finally, the nurse will make decisions based on a client's airway, breathing, circulation and neurological function.

The 4-year-old child is newly diagnosed with hepatitis A. Which instructions should the nurse reinforce with the child's parents?

Wash hands thoroughly with soap and warm water after contact with the child. The hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. The child does not have to be confined to bed and they can safely return to daycare or school one week after symptoms begin. In children under 6-years-old, who represent approximately 1/3 of all cases of hepatitis A, the disease may be asymptomatic and jaundice is rarely evident.

The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is:

To trace and screen recent contacts the client had Active tuberculosis is a reportable disease because people who had contact with the client must be traced, evaluated for the disease and possibly treated prophylactically. Statistics are kept and trends documented, but that is not the primary or most important reason for required reporting.

An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce?

Urine and saliva will be radioactive for 24 hours after ingestion. The client's urine and saliva will be radioactive for 24 hours after ingestion. The nurse should teach or reinforce teaching to double flush the commode after use, use disposable utensils and avoid close contact with children and pregnant women for seven days after therapy. Because the treatment may cause nausea, it is best that the client does not eat two hours before or after iodine administration. It is not necessary to wash laundry separately or in hot water.

The nurse is planning care for a client who is receiving radiation therapy for breast cancer. The client has a nursing diagnosis of risk for impaired skin integrity. Which of the following interventions should the nurse include in the client's plan of care?

Use a mild soap and tepid water to clean the affected area. Radiation can lead to skin changes or skin reactions in the treatment area. Skin changes are commonly seen between the gluteal folds, perineum, collar line and breast. The goal of skin care is to prevent skin breakdown and infection. Clients should be instructed to avoid wearing tight-fitting bras or belts over the treatment areas. During treatment, clients should avoid exposing their treatment areas to direct sunlight, and should also avoid swimming in saltwater and chlorinated pools. Clients should also avoid exposing their treatment area to extremes in temperature (hot or cold). To keep the affected area clean, use a mild soap and tepid water.

The nurse is admitting a client who does not speak English. Which of the following interventions should the nurse include when caring for the client?

Use a trained medical interpreter provided through the facility's interpreter services. Make a note of the client's preferred language in their medical record. Pay attention to any effort by the client to communicate. Plan on taking twice as long as usual to complete nursing interventions. Providing culturally competent care requires the nurse to advocate for clients who do not speak English or whose English proficiency is limited. Advocating for those clients can be accomplished by noting the client's preferred language in their medical record and using an agency interpreter or interpreter services. The nurse should only use a trained medical interpreter, especially for sensitive tasks such as obtaining informed consent. Using an interpreter will require more time than usual, and therefore the nurse should plan to take extra time when caring for the client. Not all interactions with the client will require a qualified interpreter. Show respect for the client by paying close attention to the client's attempts to communicate with the health care team. It is recommended to speak in a low, moderate voice and avoid excessive hand gestures, because they can give the impression that the nurse is angry and yelling at the client. The nurse should avoid using children as interpreters.

A client diagnosed with bipolar disorder has been referred to social services for possible placement in a community halfway house after discharge. The social worker telephones the nurse and asks for information about the client's mental status and adjustment. What should the nurse do next to respond to this request?

Verify that the client's medical record includes the client's written consent to release information. rational HIPAA guidelines are very strict about who has access to and can relay information. In order to release written, verbal or electronic information about a client the medical record must include a signed consent form (unless the client is a threat of harm to themselves or others). In addition, a written request for information is commonly asked for prior to the release of any client information. The nurse must also establish proof of the caller's identity before releasing information over the phone. The nurse can accomplish this by asking the social worker for a phone number, then hanging up and returning the call. This allows the nurse to verify the caller's legitimacy before providing the requested information.

The nurse is caring for a client with a chest tube. The client is confused and keeps attempting to pull out the chest tube. The nurse applies soft restraints on both of the client's wrists. Is the nurse acting appropriately?

Yes, the nurse should apply a restraint to protect the client from self-injury, and then must contact the HCP. Clients have the right to be free from physical or chemical restraints used for the purpose of discipline or staff convenience. A soft wrist restraint can be applied before a doctor's order is given, but the nurse must contact the HCP immediately after the restraint is applied to obtain the order. Sedatives are not appropriate for this client because they can make the client's confusion worse and cause central nervous system and respiratory depression. Asking a family member to stay with the client is not an appropriate intervention.