Transitions Final - All Questions from Lecture Packets

A nurse is gathering subjective data from a client being admitted to the hospital. The client tells the nurse that she has already prepared an advance directive. On the basis of this information, which action should the nurse take? A. Requesting a copy of the advance directive and placing it in the client's medical record B. Telling the client that the new hospitalization invalidates the existing advance directive C. Telling the client that it is best to prepare a new advance directive with each hospitalization D. Asking the hospital's client advocate representative to review the hospital's policies regarding advance directives with the client

A. Requesting a copy of the advance directive and placing it in the client's medical record

A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action? A. Sitting and talking to the client to alleviate his concern B. Verifying the primary health care provider's prescription C. Explaining to the client that the oral route will not permit D. Letting the client know that most medications are administered by way of the IV route when a client is hospitalized

A. Sitting and talking to the client to alleviate his concern

A novice nurse is caring for clients in a psychiatric unit. Which action(s) by the novice nurse would require the nurse supervisor to intervene? Select all that apply. A. Telling a cousin on the phone that a client has been admitted to the psychiatric unit with mania B. Informing a police officer with a court-ordered warrant about a client's prescribed medications C. Sharing information with the local news regarding a client who has recently died D. Telling the parent of an emancipated minor how substance use disorder therapy is going for the child E. Accessing a friend's electronic medical record to see if the friend has an appointment today

A. Telling a cousin on the phone that a client has been admitted to the psychiatric unit with mania C. Sharing information with the local news regarding a client who has recently died D. Telling the parent of an emancipated minor how substance use disorder therapy is going for the child E. Accessing a friend's electronic medical record to see if the friend has an appointment today

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. A. Use nonlatex gloves B. Use medications from glass ampules C. Place the client in a private room only D. Keep a latex-safe cart available in the client's area E. Avoid the use of medication vials that have rubber stoppers F. Use a blood pressure cuff from an electronic device only to measure the blood pressure

A. Use nonlatex gloves B. Use medications from glass ampules D. Keep a latex-safe cart available in the client's area E. Avoid the use of medication vials that have rubber stoppers

Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply. A. Wear a lead shield when in the client's room B. Limit visits from family to 60 minutes per day C. Wear a dosimeter film badge when in a client's room D. Allow children to visit the client as long as they are at least 12 years old E. Keep all bed linens and dressings in the client's room until the implant is removed

A. Wear a lead shield when in the client's room C. Wear a dosimeter film badge when in a client's room E. Keep all bed linens and dressings in the client's room until the implant is removed

A nurse is caring for a client who suffered a stroke. The family reports that the nurse on the previous shift failed to administer medications properly or maintain client privacy. What is the best action by the nurse? A. Complete grievance paperwork for the family and hand it to them to submit B. Inform the charge nurse of the family's concerns C. Notify the health care provider and social services D. Explain to the client's family the previous nurse's actions were accidental

B. Inform the charge nurse of the family's concerns

A nurse is describing the situations that constitute invasion of client privacy to a group of staff members. The nurse knows that which situations violate the client's privacy? Select all that apply. A. Describing a treatment to a client in a secluded area B. Telling a family member about the client's condition C. Taking photographs of a client during the client's birthday party D. Asking the client for permission to allow a nursing student to observe a procedure E. Accessing a neighbor's medical record to find out about his or her health care status

B. Telling a family member about the client's condition C. Taking photographs of a client during the client's birthday party E. Accessing a neighbor's medical record to find out about his or her health care status

A nurse educator is providing in-service sessions to the nurse staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. A. The use of latex gloves B. The use of shielded needles C. The use of recessed needles D. The use of needleless devices E. Disposal of needles in special puncture-resistant containers

B. The use of shielded needles C. The use of recessed needles D. The use of needleless devices E. Disposal of needles in special puncture-resistant containers A glove will not protect against a needle stick

A client's daughter comes to visit and talks to the client about her medical wishes. She is willing to call an attorney for assistance but asks the nurse, "What's the difference between a durable power of attorney for health care and an instructional living will? I am so confused!" Which of these responses by the nurse is correct? Select all that apply. A. "They're the same thing actually." B. "With a durable power of attorney for health care, the family decides who will serve as the client's representative." C. "The client specifies who will hold the client's durable power of attorney for health care, and that person does not have to be a family member." D. "With either of these documents you are telling your primary health care provider that you no longer want any medical care and that you want to die." E. "The living will is a legal document that tells the primary health care providers and family members what your wishes are about life-sustaining treatments if you can no longer make decisions." F. "The durable power of attorney for health care is a legal document in which you name someone else to make decisions about your health care if you are no longer able to make these decisions."

C. "The client specifies who will hold the client's durable power of attorney for health care, and that person does not have to be a family member." E. "The living will is a legal document that tells the primary health care providers and family members what your wishes are about life-sustaining treatments if you can no longer make decisions." F. "The durable power of attorney for health care is a legal document in which you name someone else to make decisions about your health care if you are no longer able to make these decisions."

A staff nurse would like to effect change to increase staffing levels on the nursing unit. What strategy should the nurse use to begin to create change on the unit? A. Assess the institutional resources available to increase staffing B. Assess the current standards of practice related to staffing C. Assess the impact of staffing on client-care quality D. Assess the effect increased staffing will have on nursing recruitment

C. Assess the impact of staffing on client-care quality

A newly hired nurse comes to the emergency department and states "I've been assigned to work here, but I don't have a computer password yet. may I use yours?" How should the nurse respond? Select all that apply. A. The nurse gives the new nurse the password, then changes it at the end of the shift B. The nurse gives the new nurse the password and asks her not to give it to anyone else C. The nurse states, "No, I can't give you my password. It's against our hospital policy to share passwords." D. The nurse states "I can't give my password to you, but I'll open the client records for you so that you can enter your own data." E. The nurse states "let's call the information technology department and see what they can do about getting a password for you."

C. The nurse states, "No, I can't give you my password. It's against our hospital policy to share passwords." E. The nurse states "let's call the information technology department and see what they can do about getting a password for you."

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? A. Obtain a court order for the surgical procedure B. Ask the EMS team to sign the informed consent C. Transport the victim to the operating room for surgery D. Call the police to identify the client and locate the family

C. Transport the victim to the operating room for surgery

A client with chronic obstructive pulmonary disease (COPD) has a signed living will with a do not resuscitate (DNR) request. While the wife was visiting the client , he had a cardiac arrest. The wife requested the client be resuscitated immediately. When the nurse hesitated to start resuscitation procedures, the wife threatened to sue the hospital. What should the nurse do? Select all that apply. a. Call the code for fear of being sued by the wife. b. Carry out the written DNR request and client wishes. c. Calmly remind the wife of the client's wishes and DNR request. d. Notify the nurse manager of the situation. e. Call the chaplain to come and remain with the wife. f. Notify the health care provider (HCP).

b. Carry out the written DNR request and client wishes. c. Calmly remind the wife of the client's wishes and DNR request. d. Notify the nurse manager of the situation. e. Call the chaplain to come and remain with the wife. f. Notify the health care provider (HCP).

The client has a peripherally inserted central line (PICC) to the right forearm. The nurse notes the dressing is wet and prepares to perform a sterile dressing change. Which nursing action reflects the use of correct sterile technique for a dressing change? Select all that apply. a. Holding objects at a level below the waist b. Reaching over the sterile field to pick up an object on the other side c. Preventing liquid from spilling onto the sterile field and permeating it d. Touching only the edges of the sterile drape with ungloved hands e. When opening the kit, opening the outermost flap away from the body while keeping the arm away from the sterile field

c. Preventing liquid from spilling onto the sterile field and permeating it d. Touching only the edges of the sterile drape with ungloved hands e. When opening the kit, opening the outermost flap away from the body while keeping the arm away from the sterile field

A client who has returned from the operating room after repair of a hip fracture is alert but confused, pulling at the IV catheter that has been inserted in her left arm. The nurse should apply which type of safety device to best keep the client from pulling out the IV line? Which type of restraint would be best for keeping the client from pulling out the IV line? a. Belt b. Wrist c. Elbow d. Mitten

d. Mitten

At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she makes which statement? a. BSE must be performed every other month b. BSE is performed on the day menstruation begins c. Monthly BSE is the only way to ensure early detection of breast cancer d. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down

d. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down

A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls in the home? A. "I took the bathmat out of my tub" B. "I use a shower chair when I bathe" C. "I've placed nightlights in my hallway" D. "The railings on my stairs are sturdy and secure"

A. "I took the bathmat out of my tub"

A hospital nurse transcribing primary health care provider's prescriptions for a client is unable to read a prescribed dosage because the handwriting is unclear. Which action should the nurse take? A. Call the primary health care provider B. Ask the client about the usual dosage of the medication C. Call the pharmacy to ask about the usual dosage of the prescribed medication D. Contact the nursing supervisor for clarification of the primary health care provider's prescriptions

A. Call the primary health care provider

The nurse transfers a child who has had open heart surgery from the intensive care unit to the pediatric unit. The child' blood pressure has been fluctuating but has been stable during the last 2 hours. What information should the nurse include in the handoff report? Select all that apply. A. Medications being used B. Current vital signs C. Drip rate for the intravenous infusion D. Time of the most recent dose of pain medication E. Current pain scale rating

A. Medications being used B. Current vital signs C. Drip rate for the intravenous infusion D. Time of the most recent dose of pain medication E. Current pain scale rating

The nurse is preparing to remove gloves, gown, mask, and eyewear worn during care of a client. Indicate in the order of priority, how the nurse would remove the contaminated items. List them from the first contaminated item to the last item the nurse would remove. a. Untie lower mask strings b. Remove mask c. Remove gown d. Remove eyewear e. Untie upper mask strings f. Remove gloves

Ans: F, D, C, A, E, B f. Remove gloves d. Remove eyewear c. Remove gown a. Untie lower mask strings e. Untie upper mask strings b. Remove mask

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear fluid, into the antecubital area. Which is the most appropriate action by the nurse? A. Call security B. Call the police C. Call the nursing supervisor D. Lock the coworker in the medication room until help is obtained

C. Call the nursing supervisor

A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. A. "I need to use night lights" B. "I need to remove my wall-to-wall carpeting" C. "I need to get handrails put up in the bathroom" D. "I need to use the staircase handrails when I go up the stairs" E. "I should walk barefoot as much as possible so that I'll know about any wet spots on the floor

B. "I need to remove my wall-to-wall carpeting" E. "I should walk barefoot as much as possible so that I'll know about any wet spots on the floor

A nurse is conducting an educational program about advanced directives for a group of adults at a local community center. The nurse explains what the directives entail and how they are used. After explaining this topic, the nurse determines that the teaching was successful based on which statement by the group? A. "The document means that there will be no treatments used for resuscitation." B. "The document allows us to choose what we want to have happen." C. "We can automatically donate our organs when this document is in place." D. "The primary care provider is the one identified as being in charge of our care."

B. "The document allows us to choose what we want to have happen."

A nurse is providing change-of-shift report on his/her assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? A. Family history B. Client needs and priorities of care C. Current diagnosis and any second diagnoses D. Results of laboratory studies conducted that day E. Client response to treatments implemented that day F. Steps used to perform the procedure for changing the client's sterile dressing at the gastrostomy tube site

B. Client needs and priorities of care C. Current diagnosis and any second diagnoses D. Results of laboratory studies conducted that day E. Client response to treatments implemented that day

The nurse employed in a hospital is waiting to receive a report from the laboratory via facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing actions? A. Call the police B. Cut up the photograph and throw it away C. Call the nursing supervisor and report the occurrence D. Call the laboratory and ask for the name of the individual who sent the photograph

C. Call the nursing supervisor and report the occurrence

The nurse is transferring an immobilized client. What is the best way for the nurse to maintain safety? Select all that apply. A. Bend at the waist to provide the power for lifting B. Keep the body straight when lifting to reduce pressure on the abdomen C. Place the feet apart to increase the stability of the body D. Relax the abdominal muscles and use the extremities to prevent strain E. Ask for assistance from another staff member

C. Place the feet apart to increase the stability of the body E. Ask for assistance from another staff member

A client who is a lawyer is admitted to a psychiatric unit for assessment. The client is angry about not being allowed to go off the unit. The client yells at the nurse, "I have rights and you must let me go outside. You are not allowed to keep me hostage here." Which would be the most therapeutic response by the nurse? A. "You cannot go outside at this time. It is not one of your rights." B. "Why are you getting so angry about not being able to leave?" C. "Your rights have been terminated while admitted to this unit." D. "You are correct; you do have rights. Let's sit and discuss them."

D. "You are correct; you do have rights. Let's sit and discuss them."

Week 11/12

Health Promotion and Maintenance - 19 questions Psychosocial Integrity - 19 questions These two lectures were combined into one week/the same lecture

Week 9

Management of Care - 37 questions on final

Week 10

Safety and Infection Control - 25 questions

A nurse is teaching a group of women health promotion strategies. Which activities are secondary prevention strategies? a. Proper use of sunscreen b. Weight-bearing exercises c. Breast self-examinations d. Papanicolaou (Pap) smear examination e. Increased intake of vegetables and whole grains

c. Breast self-examinations d. Papanicolaou (Pap) smear examination

A nurse is using a Snellen chart to assess a client's visual acuity. The client stands 20 feet from the chart, and each eye is tested separately. The client is able to read the line comprising the letters P, E, C, F, and D with each eye. The nurse encourages the client to read the next smallest line with each eye, but the client is unable to do so. How does the nurse document the client's vision? a. 20/40 b. 40/20 c. 20/30 d. 60/20

a. 20/40 Means that what the normal eye can see at 40 feet, patient can only see at 20 feet.

Which client is the most appropriate candidate for whom the nurse would assist in coordinating hospice services? a. A client with lung cancer and a 3-month life expectancy b. A client with newly diagnosed breast cancer undergoing chemotherapy and radiation therapy c. A client on hemodialysis who works as a school teacher d. A client with Guillain-Barre undergoing plasmapheresis

a. A client with lung cancer and a 3-month life expectancy

A nurse has completed a family assessment and is documenting the information obtained during the interview. The household comprises a father, a mother, one son, and two daughters. What family type should the nurse document? a. Nuclear b. Blended c. Extended d. Multi-Adult

a. Nuclear

The nurse is conducting a cultural and spiritual assessment on a newly admitted client. Which factors specifically related to culture and spirituality should the nurse address? Select all that apply. a. Nutrition b. Communication c. Insurance coverage d. High-risk behaviors e. Health care practices f. Family roles and organization

a. Nutrition b. Communication d. High-risk behaviors e. Health care practices f. Family roles and organization

The family of a client who died unexpectedly arrives to the care area. In which way should the nurse support the family at this time? Select all that apply. a. Provide emotional support. b. Serve as an attentive listener. c. Expect the family to express grief. d. Arrange for the family to view the body. e. Direct the family to the funeral home.

a. Provide emotional support. b. Serve as an attentive listener. c. Expect the family to express grief. d. Arrange for the family to view the body.

A client of Asian American descent tells the nurse he is considering using acupuncture to deal with low back pain due to strained muscles. Which question is most appropriate to ask the client? a. "Have you considered physical therapy first?" b. "Are you currently taking any anticoagulants?" c. "Have you thought about seeing a chiropractor?" d. "Can you increase your intake of rice and raw fish in your diet?"

b. "Are you currently taking any anticoagulants?"

A nurse receives a telephone call from the admissions office and is told that a child with respiratory syncytial virus (RSV) is being admitted to the hospital. Which type of precautions does the nurse prepares to institute for the child? a. Enteric b. Droplet c. Contact d. Airborne

c. Contact Adults are the ones spreading/ taking disease from one kid to another.

The nurse manager is preparing for the admission of several disaster victims from the emergency department and asks the LPN to assist in the selection of client who can be discharged to provide beds for the emergency admissions. Which clients can be safely discharged. Select all that apply. a. A client with an irregular pulse and orthopnea b. A client with a full leg cast learning to walk with crutches c. A client newly diagnosed with type 2 diabetes mellitus d. A client one day after a breast biopsy indicating a benign tumor e. A client with unstable heart failure who is being treated with medication

b. A client with a full leg cast learning to walk with crutches c. A client newly diagnosed with type 2 diabetes mellitus d. A client one day after a breast biopsy indicating a benign tumor

The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? a. Lesbian persons b. Men who have sex with men c. Women who have sex with women d. Female to male transgender persons

b. Men who have sex with men

A nurse is gathering subjective data from an adult client about the client's daily food intake. Which question should the nurse ask the client first? a. "Do you do your own shopping?" b. "Have you ever heard of MyPlate?" c. "Can you tell me what you ate and drank over the last 24 hours?" d. "Do you have adequate income to purchase the foods you need?"

c. "Can you tell me what you ate and drank over the last 24 hours?"

The nurse obtains information about a female client's health history. What is the most important question for the nurse to ask the female client to elicit data related to the contraindications to oral contraceptives? a. "Are you dieting?" b. "Did you have acne as an adolescent?" c. "Have you ever had thrombophlebitis?" d. "Do you have a family history of kidney disease?"

c. "Have you ever had thrombophlebitis?"

A nurse employed in an emergency department (ED) on the evening shift is assigned to triage arriving clients. Which client should the nurse designate as the highest priority? a. A client who twisted her ankle in a fall while inline skating b. A client with asthma who is not experiencing respiratory distress c. A client with chest pain who says that he just ate pizza made with a very spicy sauce d. A client with a minor laceration of the index finger, sustained while the client was cutting an eggplant

c. A client with chest pain who says that he just ate pizza made with a very spicy sauce

A nurse is the first responder to the scene of a train crash. Which client should the nurse attend to first? a. A victim with an apparent fractured arm b. A victim with superficial injuries on the arms and legs c. A victim who is bleeding profusely from a groin wound d. A victim with a severe head injury who is lying still and not breathing

c. A victim who is bleeding profusely from a groin wound

A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client? a. Age b. Ethnicity c. Hypertension d. Genetic inheritance

c. Hypertension

A nurse is watching a nursing student implement standard precautions as she delivers care. The nurse should intervene if the nursing student performs which incorrect action? a. Washing the hands after removing a pair of soiled gloves b. Putting on a gown and gloves to change the bed linens of an incontinent client c. Manually placing the cap on a needle after administering an IV push medication d. Wearing gloves, eyewear, and a face shield when emptying a urine drainage bag

c. Manually placing the cap on a needle after administering an IV push medication

A nurse has taught a young adult male client about testicular self-examination. Which statement indicates to the nurse that he teaching was effective? a. The client states he will perform the self-examination at least every 2 weeks. b. The client indicates the need to use both hands and palpate both testes at the same times. c. The client states that it is important to contact the healthcare provider immediately if any lumps are felt. d. The client states that he should always perform the self-examination just before getting into the shower.

c. The client states that it is important to contact the healthcare provider immediately if any lumps are felt.

During a health assessment interview, the client tells the nurse that she has some vaginal discharge. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client? a. "When was your last gynecological checkup?" b. "Have you been engaging in unprotected sexual intercourse?" c. "Don't worry about the discharge. Some vaginal discharge is normal." d. "I need some more information about the discharge. What color is it?"

d. "I need some more information about the discharge. What color is it?"

The nurse is performing an assessment of a client who is African American. Which question should the nurse ask to elicit information on a health risk associated with this cultural group? a. Does anyone in your family have arthritis? b. Does anyone in your family have thalassemia? c. Does anyone in your family have tuberculosis? d. Does anyone in your family have hypertension?

d. Does anyone in your family have hypertension?

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional values? A. Integrity B. Altruism C. Social justice D. Human dignity

A. Integrity (This is a play on veracity. This is a way that test makers can twist it. The basic principle to tell the truth applies to both)

A nurse manager is reviewing ethical principles with the nursing staff. Which example does the nurse manager provide to explain the concept of fidelity? A. Keeping a promise made to the client B. Supporting the client's right to informed consent C. Determining the order in which clients are cared for D. Avoiding harm to the client in the performance of nursing care

A. Keeping a promise made to the client

The nurse prepares to transcribe the primary health care provider's medication prescriptions. Which of the prescriptions noted in this medication record should the nurse question? Select all that apply. A. Metoprolol 50 mg/day B. Atorvastatin 10 mg/day by mouth C. Ramipril 1 tablet/day by mouth D. Levothyroxine 137 mcg/day by mouth E. Metformin and sitagliptin 50 to 1000 mg twice daily

A. Metoprolol 50 mg/day C. Ramipril 1 tablet/day by mouth E. Metformin and sitagliptin 50 to 1000 mg twice daily

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? A. "Oh, really? I will discuss this situation with your son." B. "Let's talk about the ways you can manage your time to prevent this from happening." C. "Do you have any friends who can help you out until you resolve these important issues with your son?" D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

A home health nurse has been called to the home of an older postoperative client by the client's son. The son tells the nurse, "We're using a hospital bed here at home, but my mother has fallen out of bed three times." Which observation by the nurse reflects an increased risk of the client's falling out of bed? A. The client's bed is in a low position B. The client is oriented to person, place, and time C. The caregiver uses the overbed table for feedings D. The caregiver leaves both side rails down while the client is in bed

D. The caregiver leaves both side rails down while the client is in bed

The nurse is collecting data from a Hispanic client regarding a medication history. Which cultural practice should the nurse be aware of when performing care to this population? a. This culture does not permit blood transfusions b. All questions are deferred to male members of the family c. These clients get offended if the interviewer makes direct eye contact d. This culture uses home medicines in addition to prescription medications

d. This culture uses home medicines in addition to prescription medications

A nurse spending the day with friends at an amusement park is sitting on a bench, watching people ride a roller coaster. Suddenly the nurse hears panicked screaming and sees that one car of the coaster has struck another one stopped on the track. What action should the nurse take immediately after rushing to the scene? a. Calling 911 b. Providing care to victims with life-threatening problems c. Triaging the victims and providing directions to laypersons who are willing to help the victims d. Asking someone to call the nearest hospital to let the staff know that victims of the accident will be arriving there shortly

c. Triaging the victims and providing directions to laypersons who are willing to help the victims

What assessment data place the client in a high-risk category for contracting human immunodeficiency virus (HIV)? a. A history of intravenous drug use over the past year b. A spouse with a history of vulnerability to infections c. Living in an area where the rate of HIV infection is high d. A history that includes multiple pregnancies and miscarriages

a. A history of intravenous drug use over the past year

Which intervention is an example of tertiary prevention? a. Administering digoxin to a client with heart failure b. Administering a measles, mumps, and rubella immunizations to a child c. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer d. Obtaining a finger-stick blood glucose level to screen for diabetes mellitus

a. Administering digoxin to a client with heart failure

The nurse is providing preoperative instruction for day surgery scheduled in a week to a client who speaks Spanish only. Which action is the best way for the nurse to ensure that the client understands the instructions? a. Calling for a hospital-designated interpreter to communicate with the client b. Asking for a family member who speaks English and Spanish to translate for the client c. Relying on the use of hand signals and demonstrations to teach the client about the preoperative procedures d. Writing the instructions on a piece of paper so that an English and Spanish speaking neighbor will be able to translate them for the client

a. Calling for a hospital-designated interpreter to communicate with the client

Which prescription is entered correctly on the medical record? A. Fentanyl 50 mcg given IV every 2 hours as needed of pain greater than 6/10 B. Give 4 U regular insulin IV now C. 0.5 mg MS given for IM for c/o pain D. 60.0 mg ketorolac tromethamine given IM for c/o pain

A. Fentanyl 50 mcg given IV every 2 hours as needed of pain greater than 6/10

The nurse in the emergency department is caring for an 8-year-old child brought in by ambulance after being struck by a car while riding a bike. No family member is present or reachable and the child needs emergency surgery. How would the nurse expect the need for informed consent to be addressed? Select all that apply. A. Surgery may be done without an informed consent by the family in this situation B. An emergency social worker would sign the informed consent as a parental proxy C. The ethics committee would have to convene to approve surgery in this situation D. Surgery would have to wait until one of the child's parents could provide consent E. A surgeon may choose to forgo informed consent if it is a lifesaving measure

A. Surgery may be done without an informed consent by the family in this situation E. A surgeon may choose to forgo informed consent if it is a lifesaving measure

Which event would require a nurse to complete and file an incident report? A. A client has a seizure B. The nurse determines that a client would benefit from the use of a walker to ambulate C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous pump is not working D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment

D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment

A pregnant woman expresses concern to the nurse about how her 10-year-old daughter will adapt to a newborn's introduction into the home. Which response should the nurse make to the woman? a. Most children resent a "newcomer" to the home b. An only child always has difficulty when a new baby arrives c. You must provide a great deal of attention to the 10-year-old to help prevent resentment on the older child's part d. Older school-age children often enjoy taking responsibility for the care of a younger sibling

d. Older school-age children often enjoy taking responsibility for the care of a younger sibling

An emergency department (ED) nurse receives a telephone call from the local police department and is told that several victims of an industrial explosion will be brought to the ED. Which action should the nurse take immediately? a. Calling as many off-duty nurses as possible and having them come to the hospital to care for the victims b. Following the directions outlined in the hospital's disaster preparedness (emergency response) plan c. Asking the housekeeping department to deliver an extra cart of linen containing several blankets to the ED d. Calling the operating room to inform the staff that the hospital may be receiving numerous victims requiring surgery

b. Following the directions outlined in the hospital's disaster preparedness (emergency response) plan

A nursing student arrives at the clinical nursing unit and presents a plan of care for the assigned client to the nursing instructor. The assigned client requires the use of mitten restraints because he has been pulling at his endotracheal tube. Which interventions regarding restraints in the plan of care require revision? Select all that apply. a. Ensuring that the restraint straps are attached to the bed frame b. Making sure that one finger can be inserted under the restraint c. Using a quick-release tie to secure the restraint to the bed frame d. Checking for a renewal of the primary health care provider's prescription for the restraints e. Checking skin integrity and neurovascular and cardiovascular status every hour f. Removing restraints every 2 hours for 30 minutes to perform range of motion exercises

b. Making sure that one finger can be inserted under the restraint e. Checking skin integrity and neurovascular and cardiovascular status every hour

A nurse is irrigating a client's abdominal wound when the client becomes agitated, grabs the bottle of saline solution that the nurse is using to perform the irrigation, and throws the bottle at the nurse. The nurse immediately calls for assistance. What action should the nurse take after an assistive personnel (AP) arrives? a. Asking the AP to check for a prescription for a sedative b. Leaving the room and calling the primary health care provider for a prescription for a safety device c. Stopping the wound irrigation and telling the client that she will complete the procedure when he calms down d. Asking the AP to apply a safety device to the client

d. Asking the AP to apply a safety device to the client

The nurse is writing a medication order that a health care provider provided by telephone. What should be included when writing the order? Select all that apply. A. Date the order is written B. Code status C. Medication dosage D. Client allergies E. Route of administration F. Medication ordered

A. Date the order is written C. Medication dosage D. Client allergies E. Route of administration F. Medication ordered

A client ho had a stroke has left-sided weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? A. Home care B. Social services C. Physical therapy D. Occupational therapy

A. Home care

The nurse determines that which clients are capable of giving consent? Select all that apply. A. A 15-year-old girl who believes she is pregnant B. A 17-year-old who is seeking treatment for a substance abuse problem C. A married 17-year-old who requires treatment for a suspected respiratory infection D. A 17-year-old soldier in the U.S. Army who requires sutures for a laceration sustained while home on leave E. D. A 14-year-old who requires an ankle x-ray for a fall sustained while vacationing with a friend's family

A. A 15-year-old girl who believes she is pregnant B. A 17-year-old who is seeking treatment for a substance abuse problem C. A married 17-year-old who requires treatment for a suspected respiratory infection D. A 17-year-old soldier in the U.S. Army who requires sutures for a laceration sustained while home on leave Emancipation - Saunder's pg. 64, letter B. Emancipation is when a minor is able to take care of themselves 100% financially without the support of their parents. Armed services, marriage, pregnancy, and substance abuse are cases where they can give their own consent.

A nurse is caring for a client who is scheduled for surgery. A member of the operating room staff calls the nurse and informs her that the client must be premedicated and transported to the operating room. The nurse immediately administers the sedative medication as prescribed. As the client is prepared for transport, the nurse notes that the informed consent for surgery has not been signed by the client. Which action should the nurse take? A. Contacting the client's surgeon B. Having the client sign the informed consent C. Calling the operating room to cancel the surgery D. Asking the client's significant other to sign the informed consent

A. Contacting the client's surgeon

The nurse identifies which characteristics as part of the case management approach to health care delivery? Select all that apply. A. Provides an individualized plan of care for the client B. Represents an interprofessional health care delivery system C. Involves one nurse who supervises all other primary health care providers D. Includes a comprehensive approach that promotes quality and cost-effective care E. Requires only a case manager to implement the care of the clients in the facility

A. Provides an individualized plan of care for the client B. Represents an interprofessional health care delivery system D. Includes a comprehensive approach that promotes quality and cost-effective care

The nurse administers a dose of Ramipril 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the primary health care provider and nursing supervisor of the error. What statement does the nurse add to the client's record? A. An incident report was completed and filed B. Ramipril 2.5 mg was administered at 9 am C. Twice the amount of the prescribed Ramipril was administered at 9 am D. Client's blood pressure was 128/82 mmHg after the administration of the incorrect dose of Ramipril

B. Ramipril 2.5 mg was administered at 9 am

A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child's vaccinations? A. Contact the child's health care provider (HCP) during office hours B. Review nationally published immunization guidelines C. Read each vaccine's manufacturer's insert D. Ask a local pharmacist

B. Review nationally published immunization guidelines

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best actions? A. Refuse to float based on lack of unit orientation B. Clarify the ICU client assignment to ensure that it is safe C. Ask the nurse supervisor to review the hospital policy on floating D. Submit a written proposal to nursing administration and then call a lawyer

B. Clarify the ICU client assignment to ensure that it is safe

A case manager is reviewing notations made in client's records. Which note indicates an unexpected outcome and the need for immediate follow-up? A. A client who has sustained a stroke dresses herself B. A client who exhibits signs/symptoms of increased intracranial pressure after a craniotomy C. Normal neurological findings are noted in a client with a cerebral aneurysm D. A client with a spinal cord injury transfers himself from a bed to a wheelchair

B. A client who exhibits signs/symptoms of increased intracranial pressure after a craniotomy

A primary health care provider writes a prescription for furosemide, 80 mg/day by mouth, for a hospitalized client with a diagnosis of heart failure. When the nurse brings the medication to the client, the client states that he normally takes only 40 mg of the medication each day. Which action on the part of the nurse would be most appropriate? A. Administering 40 mg instead of 80 mg B. Calling the primary health care provider who wrote the prescription C. Explaining to the client the need for a higher dose D. Checking the drug formulary and asking the client to read the information about safe dosage of the medication

B. Calling the primary health care provider who wrote the prescription

The nurse and an assistive personnel (AP) enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first? A. Complete an incident report B. Check the client's level of consciousness and vital signs C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client's primary health care provider be called

B. Check the client's level of consciousness and vital signs

A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? A. Confining the fire B. Extinguishing the fire C. Activating the fire alarm D. Returning for the fire extinguisher

C. Activating the fire alarm

A nurse is caring for a client who has end-stage chronic obstructive pulmonary disease receiving I.V. push morphine for pain management. During rounds, the nurse discusses with the physician the need to start the client on a continuous morphine infusion. The nurse bases this request on the fact that: A. Increasing morphine is considered euthanasia B. Ethically death should come quickly C. Serving as a client advocate is an important role D. Effort should be made to assist the family to cope with the end of life

C. Serving as a client advocate is an important role

A nurse is caring for a client who reports dyspnea while resting as 5 on a scale of 1-10, has a respiratory rate of 26 breaths/min, and exhibits an oxygen saturation of 96% on room air. Based on these findings, what outcome should the nurse incorporate in the plan of care? A. The client has a respiratory rate between 12-20 breaths/min and no adventitious breath sounds B. The client's oxygen saturation remains above 92% and respiratory rate under 20 breaths/min C. The client is able to perform activities of daily living without tachypnea or dyspnea above level 2 D. The client's resting dyspnea is under level 4 and respiratory rate is 12-20 breaths/min

C. The client is able to perform activities of daily living without tachypnea or dyspnea above level 2

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent, which is the best action? A. Obtain a court order for the surgical procedure B. Ask the EMS team to sign the informed consent C. Transport the victim to the operating room for surgery D. Call the police to identify the client and locate the family

C. Transport the victim to the operating room for surgery

A nurse is setting up an intravenous pump that will be used for a client who will be receiving a continuous intravenous infusion of normal saline solution containing heparin. As the nurse prepares to plug the pump's electrical cord into the wall socket, she notes that no socket is available because of other medical equipment being used in the room. Which action by the nurse is most appropriate? A. Allowing the pump to run in battery mode B. Obtaining an extension cord from the nurses' lounge C. Moving the client into the hallway, near a wall socket D. Calling the hospital's electrical department for assistance

D. Calling the hospital's electrical department for assistance

Oral contraceptive therapy has been prescribed for a client with a history of seizures who is taking phenytoin. Which information should the nurse provide to the client after reviewing the new prescription? a. An increased dosage of the oral contraceptive must be prescribed because phenytoin reduces the effectiveness of oral contraceptives b. An increased dosage of the phenytoin must be prescribed because phenytoin reduces the effectiveness of the oral contraceptive c. The primary health care provider will need to increase the dosage of the phenytoin d. The effect of the phenytoin will be magnified while the client is taking the oral contraceptives

a. An increased dosage of the oral contraceptive must be prescribed because phenytoin reduces the effectiveness of oral contraceptives

A nurse is watching an assistive personnel (AP) wash his/her hands. The nurse should intervene if the AP performs which action? a. Dries from the forearms down to the fingertips b. Uses a clean, dry paper towel to turn off the water faucet c. Uses plenty of lather and friction and scrubbing for 15 seconds d. Keeps the hands and forearms lower than the elbows while washing

a. Dries from the forearms down to the fingertips Once the hands are washed, the fingertips are considered the cleanest part of the hands. By drying from the elbow down, it is spreading the germs down the arm and onto the fingertips.

The nurse is participating in a planning session for public health services that promote primary prevention. The nurse should guide the group into selecting to focus on which aspects? Select all that apply. a. Immunizations b. Pollution control c. An exercise regimen d. Cardiac rehabilitation e. Self-examination practices f. Diabetes mellitus management

a. Immunizations b. Pollution control c. An exercise regimen