Performance by client needs; Coordinated Care

An emancipated adolescent is pregnant and plans to raise her child. She has no income or health insurance. Which recommendation should the nurse make to help the client with her health care expenses? A. Completing a Medicaid application B. Applying for Medicare C. Asking her parents for financial aid D. Providing her with the name of a lawyer to obtain child support from the baby's father

A. Completing a Medicaid application

A client addicted to alcohol begins individual therapy with a nurse. Which goal should be a priority for the client? A. Learning to express feelings B. Establishing new roles in the family C. Determining new strategies for socializing D. Decreasing preoccupation with physical health

A. Learning to express feelings

A 19-year-old client with cystic fibrosis is admitted to the hospital in acute respiratory distress. The client's mother tells a nurse that the client has been unable to get out of bed for the past month. While assessing the client, the nurse notes a stage II pressure ulcer on the client's sacrum. Which action is most important to include in the client's plan of care? Turn and reposition the client every 2 hours, monitor the wound, and document findings. Accurately document the appearance, size, location, and odor of the wound, and consult a wound care nurse. Keep the wound clean and dry, and continue to monitor it. Cover the lesion with a sterile gauze pad, and document findings.

Accurately document the appearance, size, location, and odor of the wound, and consult a wound care nurse.

The nurse sees an unauthorized person reading a client's medical record outside a client's room. Which action should the nurse take? A. Approach the individual and request the client's medical record. B. Notify the nursing supervisor and approach the individual. C. Contact security immediately. D. Document the incident on an incident report.

B. Notify the nursing supervisor and approach the individual.

A nurse is caring for a client with a diagnosis of pericarditis. Which statement might indicate a violation of client confidentiality? A. The nurse discussed the client's diagnosis with another nurse at shift report. B. The nurse discussed the client's diagnosis with a family friend over the telephone. C. The nurse discussed the client's medication therapy with the health care provider. D. The nurse discussed the client's medication therapy with the hospital pharmacist.

B. The nurse discussed the client's diagnosis with a family friend over the telephone.

The licensed practical nurse is delegating responsibilities to a certified nurse's aide on a busy postpartum unit. Which task can be appropriately delegated to the nurse's aide ? Giving the initial bath to a neonate Bottle-feeding a 24-hour-old neonate Obtaining hourly vital signs for a neonate during the transitional period Changing the diaper of a recently circumcised neonate

Bottle-feeding a 24-hour-old neonate

When reinforcing education with parents of an infant newly diagnosed with diabetes insipidus, which statement by the parent indicates an appropriate understanding of this condition? A. "When my infant stabilizes, I won't have to worry about giving hormone medication." B. "I don't have to measure the amount of fluid intake that I give my infant." C. "I realize that treatment for diabetes insipidus is lifelong." D. "My infant will outgrow this condition."

C. "I realize that treatment for diabetes insipidus is lifelong."

A pregnant client comes to the clinic after missing several scheduled prenatal appointments. During the initial assessment, the client states, "I haven't been coming to some of my appointments because I go to a homeopathic specialist who takes great care of me." Which response by the nurse is best? A. "That's fine; you can see whichever health care professional you prefer." B. "You should mention the homeopathic specialist to your physician so he can help devise the best care plan for you." C. "You really need to come to each scheduled appointment here; missing appointments could be harmful." D. "Don't you want to continue to be cared for by your clinic physician?"

C. "You should mention the homeopathic specialist to your physician so he can help devise the best care plan for you."

A client admitted to the hospital for an abdominal aneurysm repair tells a nurse that he has an advance directive . What action should the nurse take? A. Tell the client that the information will be noted in his chart, but it isn't necessary to include a copy of the advance directive. B. Instruct the client to give the advance directive to his lawyer. C. Ask the client for a copy of the advance directive to place on his chart. D. Tell the client that advance directives aren't valid when surgery is being performed.

C. Ask the client for a copy of the advance directive to place on his chart.

The nurse is caring for a school-age child with cerebral palsy . The child has difficulty eating using regular utensils and requires a lot of assistance. Which of the following referrals is most appropriate? A. Registered dietitian B. Physical therapist C. Occupational therapist D. Nursing assistant

C. Occupational therapist

The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care? A. Maintaining current weight B. Encouraging ambulation C. Promoting bowel rest D. Providing mouth care

C. Promoting bowel rest

A school-age child's family asks the nurse to describe palliative care. Which statement best describes palliative care? A. Intervention to hasten the death and dying process B. A means provided to end life C. Total care given when disease doesn't respond to curative treatment D. Action of a person to end a client's life because he's suffering from a terminal illness

C. Total care given when disease doesn't respond to curative treatment

A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction? Telling the client that such information hasn't been substantiated Supporting the client's decision because all vaccines have associated risks Encouraging the client to discuss the issue with the pediatrician at the infant's 2-week check-up Discussing the purpose of the vaccine and providing the client with written information

Discussing the purpose of the vaccine and providing the client with written information

A client with hemophilia is admitted to the medical-surgical unit. When providing care for this client, which factor is most important? Performing effective client teaching Delegating tasks effectively Ensuring client safety Maintaining continuity of care

Ensuring client safety

A client who is preparing for discharge to a halfway house must be referred to an outpatient clinic. Which criteria should be considered when choosing an outpatient treatment program for this client? The clinic is within walking distance and has scheduled treatment hours. The clinic is located 30 minutes away and has flexible treatment hours. The clinic is within walking distance, and a staff member will send a caseworker to the halfway house to assess the client and develop a treatment plan. The clinic is within walking distance and has limited treatment hours.

The clinic is within walking distance, and a staff member will send a caseworker to the halfway house to assess the client and develop a treatment plan.

A 6-month-old is brought to the emergency department with a suspected femur fracture. The parents state that the infant fell from the couch, causing the injury. The X-ray reveals a circular fracture, which is caused by forcibly twisting the extremity. Which action must the nurse take first ? Immediately ask the parents to leave the room and refuse to give them any information about the infant. Inform the parents that child abuse is suspected and social services will be notified. Treat the parents professionally and answer their questions appropriately. Call security immediately and inform them of the abuse.

Treat the parents professionally and answer their questions appropriately.

A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client? Charge nurse Physician Wound care nurse Risk management

Charge nurse

The nurse-manager has posted shift assignments on the unit. Which duty should the licensed practical nurse (LPN) refuse? A. Flushing a nasogastric tube B. Conducting the admission assessment on a new client C. Performing a sterile dressing change D. Administering oral medications

B. Conducting the admission assessment on a new client

A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives ? A. Decide on a treatment plan if the client can't. B. Inform the client or legal guardian of his right to execute an advance directive. C. Respect individuals' moral rights. D. Advise clients not to execute an advance directive because it limits treatment options.

B. Inform the client or legal guardian of his right to execute an advance directive.

A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority? Vigorously massage the fundus. Immediately call the health care provider. Have the charge nurse review the finding. Ask the client when she last changed her perineal pad.

Ask the client when she last changed her perineal pad.

The parents of a 2-year-old scheduled for surgical repair of an inguinal hernia are fearful and their fears are affecting their child. A play therapist is consulted to help with the child's care. The nurse should explain to the parents that the play therapist will: A. Allow the parents to discuss their fears and how they're affecting their child. B. Explain that a support group is available for the parents. C. Use puppets to gain insight into how the child feels about his hospitalization and fears. D. Offer financial resources for the family to alleviate anxiety.

C. Use puppets to gain insight into how the child feels about his hospitalization and fears.

The nurse is providing care for a client who underwent heart surgery and is setting goals for this client. Which is the best example of a measurable outcome goal for this client? A. Change his or her own dressing B. Walk in the hallway C. Walk from his or her room to the end of the hall and back before discharge D. Eat a special diet

C. Walk from his or her room to the end of the hall and back before discharge

After being treated with heparin for a pulmonary embolism, a client is prescribed warfarin using a sliding scale . Which action should the nurse take before administering this drug? Closely monitor prothrombin time (PT) and international normalized ratio (INR) results to determine the dose of warfarin to administer. Notify the physician of PT and INR results before administering the next dose of warfarin. Administer the next dose of warfarin and then notify the physician if PT and INR results are abnormally high. Administer the next dose of warfarin and then notify the physician if PT and INR results are abnormally low.

Closely monitor prothrombin time (PT) and international normalized ratio (INR) results to determine the dose of warfarin to administer.

A 25-year-old client comes to the emergency department with her clothes torn. She has visible cuts, bruises, and profuse vaginal bleeding. A nurse suspects that this client has been raped . What should the nurse do? Assist the client with bathing. Apply ice packs to the bruised areas. Collect forensic evidence. Notify a psychiatrist who is on call.

Collect forensic evidence.

The nurse is providing care to a client with Alzheimer's disease (AD). Which nursing intervention takes top priority? A. Establish a routine that supports former habits. B. Maintain physical surroundings that are cheerful and pleasant. C. Maintain an exact routine from day to day. D. Control the environment by providing structure, boundaries, and safety.

D. Control the environment by providing structure, boundaries, and safety.

New evacuation procedures are being developed for the unit by a task committee at the long-term care facility, but have not been approved. A bomb threat has occurred in the facility. Which action is appropriate by the nurse? A. Tell staff members to use whatever procedures they feel are best. B. Ask staff members to quickly meet among themselves and decide what procedures to follow. C. Tell staff members to assemble in the staff lounge to quickly offer their opinions about what to do. D. Determine that the procedures currently in place must be followed.

D. Determine that the procedures currently in place must be followed.

A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives? Decide on a treatment plan if the client can't. Inform the client or legal guardian of his right to execute an advance directive. Respect individuals' moral rights. Advise clients not to execute an advance directive because it limits treatment options.

Inform the client or legal guardian of his right to execute an advance directive.

A nurse approaches a client with an 0800 dose of his scheduled pancreatin . The client states, "I'm not going to take that medicine. It makes me nauseated." What should the nurse do first? Tell the patient that he is required to take all prescribed medications. Ask the client to talk to his physician about changing the medication. Instruct the client about the benefit of taking the medication. Delay giving the medication until later in the day.

Instruct the client about the benefit of taking the medication.

Which action must a nurse take first before drawing a blood sample for human immunodeficiency virus (HIV) testing? Make sure that an informed consent form has been signed. Inform the client that the sample is being obtained for routine testing. Put on gloves and a mask. Tell the client that he'll be informed if the test results are positive.

Make sure that an informed consent form has been signed.

A client with a suspected diagnosis of renal cancer is ordered to undergo a renal biopsy to confirm the diagnosis. The client informs a nurse that she will not sign the informed consent form. Which action should the nurse take? Explain the importance of signing the consent form. Request that the client's husband sign the consent form. Notify a physician that the client refuses to give consent. Inform the client that she's delaying treatment by refusing to sign the consent form.

Notify a physician that the client refuses to give consent.

The nurse would explain to the parents of a newborn with a cleft lip and palate that they will need to schedule an appointment with which specialist? Cardiologist Neurologist Nutritionist Otolaryngologist

Otolaryngologist

A 27-year-old client with end-stage acquired immunodeficiency syndrome (AIDS) is being cared for by his wife at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about advance directives . At the next visit, the client states that since he and his wife filled out the advance directive form he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client 's concerns? A. "Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself." B. "Many people feel that way when they are admitted into hospice. Although the focus of your care has changed from curative to supportive, your physician will still continue directing it."

A. "Your physician will continue to care for you. Advance directives document in writing your wishes regarding your care in case you're unable to communicate them to the physician yourself."

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action is most appropriate for the nurse to take? A. Clearing the client's airway B. Making the client comfortable C. Starting cardiopulmonary resuscitation D. Stopping the feeding and removing the NG tube

A. Clearing the client's airway

A nurse is working with a nursing assistant, who is given the task of calculating three clients' intake and output at the end of the shift. When the nurse reviews the nursing assistant's work, she discovers inaccuracies in the nursing assistant's results. What should the nurse do? Report the problem to the shift supervisor or nurse-manager. Avoid assigning this task to the nursing assistant in the future. Schedule the nursing assistant for a class on calculating intake and output. Ask the nursing assistant to show her how she determined the results.

Ask the nursing assistant to show her how she determined the results.

A nurse is caring for a client who underwent a total hip replacement. Which intervention should the nurse implement in this client's care to prevent dislocation of the new prosthesis? Explain that the client's advance directive appoints the physician as the power of attorney for health care decisions. Use measures other than turning to reduce the possibility of pressure ulcers. Avoid moving the extremity into positions that cause internal rotation. Place several pillows under the knees to maintain hip flexed.

Avoid moving the extremity into positions that cause internal rotation.

The nurse is making assignments for the unlicensed assistive personnel (UAP). Which tasks can be safely assigned to UAP? Select all that apply. A. Assisting a client with a chest tube during ambulation B. Feeding a client with swallowing difficulty C. Teaching a client how to use the cane D. Bathing a client with Alzheimer's disease E. Turning a client who is poorly nourished

D. Bathing a client with Alzheimer's disease E. Turning a client who is poorly nourished

After a physician describes the surgical procedure for lumbar spinal fusion and its associated risks, the nurse provides a consent form for the client to sign. The client asks the nurse what the term "fusion" means and whether he'll lose a lot of blood during the procedure. Which action should the nurse take? Explain the surgical procedure and the typical blood loss associated with it. Notify the physician of the client's questions about the procedure before having the client sign the informed consent form. Request that the charge nurse answer the client's questions about the procedure. Inform the client that the operating room nurse can clarify any questions before the procedure.

Notify the physician of the client's questions about the procedure before having the client sign the informed consent form.