practice exam
A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is a neighbor's son. What action should the nurse take?
Inform the nurse director reading the chart is a violation of the client's right to privacy and ask the nurse director to return the chart. Personal health information may not be used for purposes not related to health care. The nurse director found reading the chart is not providing health care to the client and therefore does not require access to the chart. The nurse should confront the nurse director and request the return of the client's chart. The director should not have access to this client's health care information regardless of the client's HIV status. If the nurse director does not comply with the nurse's request, the nurse should report the incident to the nurse manager, so the infraction can be reported through the proper channels. The staff nurse should not report the incident to the medical director. Asking the nurse director about permission from a medical director to read the chart does not protect client confidentiality.
Detention center staff asked for a mental health evaluation of a 21-year-old woman after the client stabbed themself with a fork and woke from nightmares in fits of rage. The evaluation revealed that the client was kidnapped and held from ages 8 to 16 by a convicted child pornographer. The client said they never contacted their family after being released from captivity. In what order of priority from first to last should the nurse implement the steps? All options must be used.
Initiate suicide precautions. Offer empathy and support, and be nonjudgmental and honest with the client. Encourage safe verbalizations of the client's emotions, especially anger. Ask the client if they wish to contact the their family while hospitalized. Safety is a priority after the client stabbed herself. A survivor of trauma/torture needs empathy, support, honestly, and a nonjudgmental stance from the nurse. Then the client is more willing to learn safe ways to express feeling, especially anger. It will be the client's decision if the client wants to contact their family and, if so, under what conditions. The client would need extensive preparation before any contact with family.
A nurse is assisting in the discharge planning for a client with alcoholism. Which actions should be included in the discharge plan? Select all that apply.
Strongly encourage participation in Alcoholics Anonymous (AA). Provide nutritional information and counseling. Establish an exercise program. Discuss relapse prevention. AA is an outpatient support group for recovering alcoholics. It allows clients to share their problems and gain support from members of the group to avoid further alcohol abuse. The nurse should strongly encourage the client to participate in this support group. The nurse should provide the client with nutritional information and counseling, particularly if the client is underweight or malnourished. Establishing an exercise program is appropriate for the client's physical health. The nurse should discourage the client from reestablishing relationships with former "drinking friends" because this could lead to relapse.
A client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements by the client indicate that client teaching has been effective? Select all that apply.
"I need to call my healthcare provider to discuss my steroid needs before I have dental work." "I'll call the healthcare provider if I suddenly feel profoundly weak or dizzy." "I need to obtain and wear a Medic Alert bracelet." Addison's disease is a chronic endocrine disorder that occurs when the adrenal glands do not produce enough hormones such as cortisol and aldosterone. These hormones give instruction to virtually every tissue and organ in the body. Dental work can be a cause of physical stress; therefore, the client's healthcare provider needs to be informed about the dental work so adjustments in the dosage of steroids can be made, if necessary. Fatigue, weakness, and dizziness are symptoms of inadequate steroid therapy; the healthcare provider should be notified if these symptoms occur. A Medic Alert bracelet allows health care providers to access the client's history of Addison's disease if the client is unable to communicate this information. A client with Addison's disease does not produce enough steroids, so routine administration of steroids is a lifetime treatment. Daily weight should be monitored to monitor changes in fluid balance, not calorie intake. A viral illness is an added physical stressor that may require an increased dosage of steroids. The client should notify the healthcare provider, not "carry on as usual."
The nurse is caring for an infant following the surgical repair of a cleft lip. The infant's pain is being managed effectively. What does the nurse determine is the priority goal for this client?
After surgery, a priority nursing goal is to prevent infection. Surgery involves an incision on skin and mucus membranes, which places the infant at risk for infection. It is important that the infant not touch the incision line or disrupt the sutures. The infant's arms are placed in restraints to keep them from touching the suture line or attempting to suck on their fingers. Teaching the parents to feed with special feeders or with a spoon is a necessary part of recovery care. Nutrition should be maintained throughout the recovery process and will improve as the infant is better able to grasp the nipple to suck. The mother will be taught how to feed the baby with special feeding devices. Many parents are already using these devices at home to feed the child.
A home care nurse is making a visit with a client who has a colostomy. While the nurse is changing the client's appliance, the client's next-door neighbor wants to visit. Which intervention by the nurse is most appropriate? Select all that apply.
Have the neighbor wait in the next room until the appliance is changed. Ask the neighbor to come back in 20 minutes. The home care nurse should either ask the neighbor to wait in the other room or come back in 20 minutes. Client privacy is a priority even in the home care setting. Allowing the neighbor to enter the room violates client privacy and confidentiality. Suggesting the neighbor come in and learn how to change the appliance is inappropriate because the client did not request help from the neighbor.
A client is diagnosed with metastatic adenocarcinoma of the stomach. The physician orders mitomycin and other chemotherapeutic agents for palliative treatment. How does mitomycin exert its cytotoxic effects?
It inhibits deoxyribonucleic acid (DNA) synthesis.
The nurse is assessing a client with a spinal cord injury for the development of deep vein thrombosis. Which is the most effective way to determine deep vein thrombosis in this client?
Measure leg girth. Measuring the leg girth is the most appropriate method because the usual signs, such as a positive Homans' sign, pain, and tenderness, are not present. Other means of assessing for deep vein thrombosis in a client with a spinal cord injury are through a Doppler examination and impedance plethysmography.
A 6-year-old child is admitted to the pediatric unit for evaluation of recurrent abdominal pain. The child has been admitted to the pediatric unit with similar complaints several times in the past few months. The child's symptoms are vague, yet the child's parent provides detailed information about the problem. The nurse is suspicious of the situation. What should the nurse do next?
Notify the physician and request assistance from the interdisciplinary team. The child's clinical presentation and the parent's behavior suggest factitious disorder imposed on another, a condition in which an individual fabricates or induces symptoms of a disorder in another person. Suspicion of this condition mandates a coordinated evaluation by the healthcare team. Rather than asking the parent to leave, the nurse should establish a rapport with the parent. Doing so will prevent the parent from becoming suspicious and leaving the health care organization, which would potentially allow the cycle to continue. The nurse must contact authorities when additional evidence is obtained.
The nurse is assessing a client during a home health visit. The client reports a severe burning on urination. What is the most important action by the nurse?
Obtain a urine specimen from the client. Though it is suspected that the client has a urinary tract infection (UTI), a urine specimen is needed to determine specific treatment. After obtaining the specimen, comfort measures can be provided pending the results which may take 24 to 72 hours. Drinking large amounts of water will help flush bacteria from the urinary tract, but it is not bacteria specific. Cranberry juice increases the acidity of urine and helps to prevent UTIs; however, it does little to treat a UTI. A sitz bath may provide comfort but does not address the priority need.
A nurse notices that a severely depressed client is crying and asks what's wrong. The client responds, "Well, it looks like my suspicions are about to be confirmed." When asked what that means, the client refuses to talk about the matter. The nurse later notices a letter from the client's spouse lying on the floor near the bed. The client is in session with the psychiatrist and the nurse believes the contents of the letter could offer clues about the client's depression. What is the nurse's best course of action?
Pick up the letter and place it on the client's bedside table. One of the basic client rights is the right to send and receive unopened mail. Placing the letter on the client's bedside table is the professional response. Reading the letter is inappropriate and violates the client's rights. Asking the client if the nurse may read the letter is too direct and invasive and may alienate the client. The nurse might consider using indirect communication at a later time and invite the client to share the contents of the letter if comfortable doing so.
The nurse is caring for an older adult with mild dementia admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply.
Reorient frequently to time, place and situation. Arrange for familiar pictures or special items at bedside. Spend time with the client, establishing a trusting relationship. It is not unusual for the elderly client to become somewhat confused when "relocated" to the hospital, and this may be more difficult for those with known dementia. Frequent reorientation delivered patiently and calmly along with placing familiar items nearby so the client can see them may help decrease confusion related to hospitalization. Establishing a trusting relationship is important with every client but maybe more so with this client. Putting the client in a room further from the nursing station may decrease extra noise for the client, but will also make it more difficult to observe the client and maintain a safe environment. Procedures should be explained to the client prior to proceeding and should not be rushed. Visits by family and friends may help to keep the client oriented.
The nurse is administering bolus gastrostomy feedings to an infant after surgery to correct a tracheoesophageal fistula (TEF). What should the nurse do to prevent air from entering the stomach once the syringe barrel is attached to the gastrostomy tube?
Unclamp the tube after pouring the complete amount of formula to be administered into the syringe barrel. The best way to prevent air from entering the stomach when performing a bolus feeding on an infant through a gastrostomy tube is to open the clamp after all the formula has been placed in the syringe barrel. Doing so prevents air from mixing with the formula and thus being introduced into the stomach. Pouring all the formula into the barrel after opening the clamp, maintaining a continuous flow of formula down the side of the barrel after unclamping the tube, and allowing a small amount of formula to enter the stomach before adding more formula to the barrel permit air to enter the stomach.
A client who is scheduled for an open cholecystectomy has been smoking a pack of cigarettes a day for 20 years. For which postoperative complication is the client most at risk?
atelectasis The client who has a significant cigarette smoking history and an operative manipulation close to the diaphragm (the gallbladder is against the liver) is at increased risk for atelectasis and pneumonia. Postoperatively, this client will be reluctant to deep breathe because of pain, in addition to having residual lung damage from smoking. Therefore, the client is at greater-than-average risk for pulmonary complications. The client does not have an increased risk of prolonged immobility (unless slowed by a respiratory problem), deep vein thrombosis (as long as the client performs leg exercises), or delayed wound healing (as long as the client maintains appropriate nutrition).
A nurse is caring for a client in labor. Which assessment finding indicates fetal distress?
fetal blood pH less than 7.2 A fetal blood pH less than 7.2 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.2 to 7.3 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. Lack of meconium staining, early decelerations in fetal heart rate during contractions, and an increase in fetal heart rate with fetal scalp stimulation are all normal findings.
The nurse is caring for a client in the newborn nursery. What appropriate actions can the nurse take that will help to prevent neonatal infection? Select all that apply.
good hand washing technique isolation of infected infants with communicable disease hand sanitizer with points of contact For population health measures, hand washing and using hand sanitizer remain the most important infection control procedure for contact with all newborns. The caregiver should wash their hands before and after each newborn contact. Isolation of infected infants also prevents the spread of infection. A separate gown technique is not necessary in most situations unless the infant is infectious and has a communicable disease. Covering the umbilical cord with sterile gauze is also unnecessary to prevent infection in the infant.
Allopurinol is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which adverse effect of this medication?
maculopapular rash Allopurinol is used to treat renal calculi composed of uric acid. Adverse effects of allopurinol include drowsiness, maculopapular rash, anemia, abdominal pain, nausea, vomiting, and bone marrow depression. Clients should be instructed to report rashes and unusual bleeding or bruising. Retinopathy, nasal congestion, and dizziness are not adverse effects of allopurinol.
A nurse who is a case manager is responsible for assigning client care to unlicensed assistive personnel (UAPs). The nurse is planning the care for a new pediatric client who requires several treatments. Which UAP will the nurse assign to care for the new client?
the UAP who has independently provided the same treatments to clients in the past The nurse is accountable for the assignment of tasks to UAPs. The nurse must ensure that the care being assigned is consistent with the UAP's level of knowledge, skill, and judgment. Assignments must also consider the UAP job description, agency policy, legislation, and client need. Friendliness and time management skills are traits that may enhance delivery of care, but they do not meet the requirements for safely assigning client care. Supervised practice does not ensure competency.
