ATI Integrated Test

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following? A) Facial edema B) Urinary frequency C) Acid indigestion D) Breast leakage

A) Facial edema The content of this question emphasizes the concept of client education by determining manifestations the client should be taught to immediately report to the provider. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for the client to be taught symptoms that should be immediately reported to the provider to prevent or reduce potential harm to herself or the fetus. Facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider.

A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication? A) Speech pathologist B) Occupational therapist C) Social worker D) Respiratory therapist

A) Speech pathologist Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making, as well as achieve continuity of care and positive client outcomes. A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy. The speech pathologist should attend the next meeting to address difficulty swallowing in a client who has had a cerebrovascular accident.

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first? A) Take an ABG specimen to the laboratory. B) Transport a client to the radiology department for an x-ray. C) Obtain a clean catch urine sample from a newly admitted client. D) Pass fresh water to clients.

A) Take an ABG specimen to the laboratory. Take an ABG specimen to the laboratory. MY ANSWER The content of this question emphasizes the concept of leadership by prioritizing completion of assigned tasks. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. When making assignments, a leader should be certain to include a timeline for completion. ABG samples are kept on ice and should be transported immediately to the laboratory or the specimen will deteriorate, which will cause inaccurate and meaningless results. This is the task the nurse should instruct the AP to perform first.

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? A) "I will only be on this medication 4 to 6 months because it can lead to physical dependence." B) "I can have 1 to 2 alcoholic beverages each week." C) "I will need to stop taking Xanax two weeks before I can begin taking this medication." D) "I can have 6 to 8 ounces of grapefruit juice each day."

B) "I can have 1 to 2 alcoholic beverages each week." The content of this question emphasizes the concept of client education by determining which statement by the client indicates effectiveness of the teaching. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. Buspirone is an anxiolytic medication used to treat anxiety, but is different from benzodiazepines because of the fact that it is not a CNS depressant. Because of this, buspirone does not interfere with CNS depressants, such as benzodiazepines, alcohol, or barbiturates, and it is acceptable to have 1 to 2 alcoholic beverages each week. This statement by the client is true and indicates an understanding of the teaching.

A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). Which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy? A) 0.25 mEq/L B) 0.75 mEq/L C) 1.5 mEq/L D) 2.25 mEq/L

B) 0.75 mEq/L To answer this item, you need knowledge of therapeutic serum lithium level levels. Based on your understanding of this information, you can select the option with the serum lithium level appropriate for maintenance therapy. This item requires foundational thinking because you have to recall knowledge of therapeutic serum lithium levels. Lithium is a mood-stabilizing medication used in the treatment of bipolar I acute and recurrent manic and depressive episodes. To achieve a therapeutic range, give 300 mg to 600 mg of lithium during the active phase. The therapeutic serum lithium level is between 0.8 mEq/L and 1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are prescribed lithium for long-term therapy. Because small increments of dosage separate therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for maintenance therapy.

A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles? A) Justice B) Autonomy C) Veracity D) Fidelity

B) Autonomy Autonomy is respecting the client's right to make personal health care decisions, whether or not the nurse believes those decisions are in the best interest of the client. This is the ethical principle the nurse is illustrating by making the referral as requested.

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A) Pupil dilation B) Ataxia C) Lethargy D) Bradycardia

C) Lethargy The content of this question emphasizes the concept of safety through the identification of an initial manifestation of increased ICP. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating potential complications, nurses are better able to predict a needed intervention, which assists in preventing or minimizing physical or psychological harm to the client. Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in the level of consciousness, such as restlessness, irritability, and disorientation, lethargy is the first sign of increased ICP.

A nurse is collecting data on four clients. Which of the following is more urgent? A) Bladder distension and urgency B) Pedal edema C) Warmth and pain in the calf D) Hypoactive bowel sounds

C) Warmth and pain in the calf Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is warmth and pain in the calf of a client. Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the most urgent need. This option is further supported by the ABC priority setting framework.

A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-aged child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching? A) "I will be sure to use the nebulizer four times per day." B) "I can't use my cromolyn nebulizer for a sudden asthma attack." C) "It will be several weeks before I notice an improvement in my asthma." D) "I will use my cromolyn nebulizer before using my albuterol inhaler."

D) "I will use my cromolyn nebulizer before using my albuterol inhaler." In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client needs further teaching. You will learn more about negatively worded items in Module 4.This item requires foundational thinking because you have to recall knowledge to determine which of the client's statements about cromolyn was false. "I will use my cromolyn nebulizer before using my albuterol inhaler" is not a true statement and indicates a need for further teaching. Cromolyn is an inhalation agent used to reduce bronchial inflammation and for the prophylactic management of mild to moderate asthma. Education to the client about the medication should specifically include that it is not effective for quick relief, and that when administered routinely on a set schedule, both the frequency and intensity of asthma attacks is decreased. However, it is also important to note that cromolyn can reduce exercise-induced bronchospasms when administered 15 min prior to anticipated exertions. When both cromolyn and albuterol are prescribed, albuterol should be inhaled first to open the airways because is a bronchodilator. After waiting a few minutes, the cromolyn can then be inhaled and will reach further into the lungs because of the dilatory effects of albuterol.

A school nurse has requested the school board to remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following? A) Deontology B) Morality C) Principlism D) Advocacy

D) Advocacy In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. A legal and ethical responsibility of nurses is to protect the rights of clients and provide safe, quality nursing care. Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a person, group, or community. The nurse made the request to remove the playground equipment on behalf of and to benefit the children of the school. This is an example of advocacy.

A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness? A) Rapid weight gain B) Tar-colored stools C) Lethargy D) Dark urine

D) Dark urine In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree. The biliary tree begins as many small ducts that join together into one main common bile duct, similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to the small intestine where bacteria break it down into urobilinogen to be excreted in the feces. Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the liver and being excreted in the urine. The nurse should teach the parent that dark urine is a clinical manifestation associated with the illness.

A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter migrated to the jugular vein. Which of the following actions should the nurse take first? A) Notify the provider. B) Obtain a chest x-ray. C) Flush the catheter. D) Stop the infusion.

D) Stop the infusion. The content of this question emphasizes the concept of priority setting by determining the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. Stopping the infusion is the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. This prevents further damage to vessel and minimizes any additional harm to the client.

Match the quality improvement process to the appropriate description: : Structure Audit A) The procedure of reviewing the standards that are followed in the delivery of care. B) Analysis of the actual result, or impact, of delivered care. C) Performed in response to a sentinel event by collecting and analyzing related data, and outlining corrective actions. D) Process of planning improvement strategies, implementation of those strategies, analyzing the impact of the strategies, and making changes to strategies as needed. E) Evaluation or measurements of the impact of environmental resources and influences have on the provision of care.

E) Evaluation or measurements of the impact of environmental resources and influences have on the provision of care. The structure audit is appropriately matched with description E. Audits are useful in evaluating performance, as well as measuring the quality of delivered care. A structure audit is the evaluation or measurement of the impact structures, such as environmental resources and influences have on the provision of care.

A nurse is reinforcing teaching about HIV with a group of high school students. What type of symptoms does HIV manifest as initially?

Flu like symptoms

A nurse realizes she made a medication error. What is her first priority after the realization?

Make sure the patient is safe. THEN file an incident report. It is always best to ensure the patient's condition before getting involved in paperwork. The incident report should NOT be included in the patients chart as they are only used for quality improvement programs and should not be included in the patient's permanent record.

A nurse is caring for a patient who has nausea and has a prescription for promethazine (Phenergan) 25 mg IM. How should the nurse withdraw the medication from an ampule?

Set the ampule on a flat surface to withdraw the promethazine. This action by the nurse is appropriate. To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle.

When should a patient discontinue ethambutol?

When the patient reports loss of color discrimination. Ocular toxicity is a visual disturbance that includes a change in color vision and visual acuity. Treatment should be stopped immediately if this occurs.

Isoniaziad and ethambutol are both drugs used to treat what condition?

pulmonary tuberculosis

A nurse is caring for a client who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? A) Promoting oxygenation B) Management of pain C) Maintaining hydration D) Preventing infection

A) Promoting oxygenation Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are the priority concerns of the nurse caring for a client who has been admitted in a vaso-occlusive crisis. Short-term oxygen therapy is used to prevent additional sickling and hypoxia. Massive systemic sickling has been linked to severe hypoxia and can be fatal. Rest should also be encouraged to decrease expenditure of energy and oxygen. Based on this knowledge and using the ABC priority setting framework, promoting oxygenation is the nurse's priority concern.

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile? A) Prospective audit B) Outcome audit C) Process audit D) Structure audit

B) Outcome audit The content of this question emphasizes the concept of quality improvement by selecting the appropriate audit to conduct when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile. The primary goal of quality improvement is developing and implementing a plan to improve health care services and better meet the needs of clients. To accomplish this goal it is necessary to recognize client and facility issues that impact the provision of safe, quality care, as well as identify gaps between current practices and best practices. Audits are a process of measuring the quality of delivered care so better practices can be developed and implemented when needed. An outcome audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes. This type of audit is appropriate to use when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile.

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first? A) Bathe a client who is scheduled for physical therapy at 9 a.m. B) Perform fingersticks for glucose levels on clients who have diabetes mellitus. C) Stock procedure rooms. D) Distribute clean linens.

B) Perform fingersticks for glucose levels on clients who have diabetes mellitus. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Performing fingersticks for glucose levels on clients who have diabetes mellitus is important in order to ensure physiological safety of the clients. Using the safety and risk reduction priority setting framework and nursing knowledge, the greatest risk to the client is hyperglycemia or hypoglycemia because of inadequate or inappropriate amounts of insulin being administered. To attain accurate readings, these levels should be attained prior to eating; therefore, this is the task the nurse should have the AP perform first.

A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention? A) Blood glucose 150 mg/dL B) Potassium 2.5 mEq/L C) Total protein 5.2 g/dL D) Urine specific gravity 1.040

B) Potassium 2.5 mEq/L The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding requires immediate intervention. A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmias or cardiac arrest. Because this level is life threatening, it is the priority at this time.

A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is the priority concern of the nurse? A) Enhancing self-esteem B) Preventing injury C) Encouraging problem solving D) Promoting usefulness

B) Preventing injury Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The second level of Maslow's Hierarchy of Needs includes needs associated with safety and security; therefore, preventing injury is the priority action of the nurse.

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate? A) "I know this must be difficult, but your mother will calm down soon." B) ​"Let's discuss some strategies you can use when this happens again." C) "Individuals near death are ready to let go toward the end." D) "Have you determined why she is crying and saying she is ready to die?"

B) ​"Let's discuss some strategies you can use when this happens again." The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication assists the nurse to develop client relationships that foster trust and respect. This response by the nurse offers to provide information, which can reduce anxiety and enhance decision-making. This response by the nurse creates a safe and secure environment, fosters trust and respect, and is appropriate.

A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate? A) "I know this must be frightening, but you are going to be fine." B) ​"Let's talk for a minute about your concerns." C) "You were transferred because it is in your best interest." D) "Why do you feel a family member should be with you?"

B) ​"Let's talk for a minute about your concerns." The use of therapeutic communication helps develop nurse-client relationships that foster trust and respect. "Let's talk for a minute about your concerns" is an appropriate response by the nurse. Discussing the client's concerns and providing appropriate information will lower the client's anxiety level and establish an environment of open communication.

A nurse is collecting data for a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication? A) Weight loss B) ​WBC 2,800/mm3 C) Heart rate 64/min D) Insomnia​

B) ​WBC 2,800/mm3 ​In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Clozapine is a second-generation antipsychotic used to relieve symptoms of schizophrenia and to reduce suicidal behaviors in clients who have schizophrenia or schizoaffective disorder. Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis, which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal. Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3 indicates the client is experiencing an adverse effect of the medication.

A nurse is caring for a client following a bronchoscopy. Which of the following requires immediate intervention? A) Painful swallowing B) Hoarse voice C) Difficulty breathing D) Blood-tinged sputum

C) Difficulty breathing Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This finding can lead to hypoxia; therefore, immediate intervention is warranted. The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication.

A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority? A) Hematocrit 32% B) WBC 16/mm3 C) Slurred speech D) Yellowed sclerae

C) Slurred speech To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. Sickle cell anemia is characterized by the partial or complete replacement of mature hemoglobin with sickled hemoglobin. The sickled shape of cells can block or reduce the flow of blood through blood vessels, resulting in complications. Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral infarction, which leads to neurological impairment. Because a CVA threatens the life of the client, this is highest priority finding.

A nurse is caring for a school aged child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? A) Provide a toy doctor's kit to play with. B) Keep all syringes and needles out of sight until needed. C) Use an approach that is firm but direct. D) Allow the child to manipulate the medical equipment.

D) Allow the child to manipulate the medical equipment. The content of this question emphasizes the concept of client-centered care by implementing age-appropriate strategies to prepare a client for a procedure. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using age-appropriate strategies, nurses facilitate the provision of individualized, high-quality care. Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure.

HbA1c levels directly correlates to what?

A hemoglobin A1c (HbA1c) test measures the amount of blood sugar (glucose) attached to hemoglobin. Hemoglobin is the part of your red blood cells that carries oxygen from your lungs to the rest of your body. An HbA1c test shows what the average amount of glucose attached to hemoglobin has been over the past three months.

A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching? A) "I will have my husband wear a condom during intercourse." B) "I will check my temperature every 4 hours." C) "I will wipe from front to back after bowel movements." D) "I will notify my doctor if my baby moves fewer than 4 times in the 2 hours following each meal."

A) "I will have my husband wear a condom during intercourse." The content of this question emphasizes the concept of client education by determining the need for additional teaching. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. The client who has experienced a premature rupture of membranes should not engage in sexual activity or insert anything in the vagina because of the increased risk for infection. This statement by the client indicates a need for additional teaching.

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions? A) A client who has rubella B) A client who has measles C) A client who has hepatitis A D) A client who has Rocky Mountain spotted fever

A) A client who has rubella To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Rubella is transmitted through the nasopharyngeal secretions of the infected person, and is also found in blood, stool, and urine. Because droplets associated with the illness are larger than 5 mcg, the Centers for Disease Control and Prevention recommends placing clients who are diagnosed with rubella on droplet precautions. Droplet precautions include placing the client either in a private room or with other clients who have the same disease, as well as using of a mask or respirator when providing care. This client should be placed on droplet precautions.

A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform an electronic blood pressure measurement? A) A client who is recovering from a cardiac catheterization B) A client who is in stage 4 of Parkinson's disease C) A client who has anorexia and hypotension D) A client who has a temperature of 39.1° C (102.4° F) and is shivering

A) A client who is recovering from a cardiac catheterization In this item, you need nursing knowledge of how blood pressure measurement can be impacted by the stages of Parkinson's disease, hypotension, shivering, and cardiac catheterization. Additionally, specific knowledge of electronic blood pressure measurement is needed to select the correct option. This item requires critical thinking because you have to analyze the four clients and determine for whom an electronic blood pressure is appropriate. Shivering can result in an inaccurate reading by causing the sensor to detect the outside interference instead of blood rushing through the artery. It is not appropriate to perform an electronic blood pressure measurement on this client.

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the client's code status to do-not-resuscitate (DNR)? A) A written prescription from the provider B) Signed documentation from the client C) Family support of the decision D) Admission to hospice for palliative care

A) A written prescription from the provider In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. A DNR is typically instituted at the request of a client or family member and should be a written order instead of a verbal prescription. Until a DNR prescription exists, every attempt to revive the client should be made in the event of respiratory or cardiac arrest. A written prescription from the provider is necessary to legally change the client's code status to a DNR.

A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? A) Check on the client. B) Unlock the crash cart. C) Begin cardiopulmonary resuscitation. D) Announce a code.

A) Check on the client. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. If the client is able to be aroused or a pulse is palpated, then the client is not in cardiac arrest, and there is a problem with the monitoring equipment. It is common for leads to become loose or fall off clients when they move around, resulting in the monitor detecting an absence of cardiac function. Therefore, checking on the client is the first action the nurse should take.

A nurse is reinforcing teaching with a caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching? A) Cue the client by providing picture cards that portray common needs. B) Increase the volume of the voice when speaking to the client. C) Encourage the client to limit hand gestures when communicating. D) Vary the use of phrases and terminology in discussions.

A) Cue the client by providing picture cards that portray common needs. The content of this question emphasizes the concept of client education by determining the appropriate communication strategy to include in teaching to the caregiver of a client who has aphasia. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. Appropriate communication techniques will enhance the caregiver's ability to care for the client, as well as the client's self-expression, thereby ensuring the client's needs are met. Clients who have aphasia have difficulty expressing themselves and understanding what is being said. Using picture cards that portray common needs provides cues for the client and enhances communication. The nurse should include this communication strategy in the teaching.

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? (Select all that apply.) A) Dietician B) Physical therapist C) Hospice nurse D) Social worker E) Respiratory therapist

A) Dietician B) Physical therapist D) Social worker The content of this question emphasizes the concept of the interdisciplinary collaboration by recognizing the health care professionals that should be present at an interdisciplinary team meeting for a client who is diabetic and is being discharged home following an above-the-knee amputation. Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making, as well as achieve continuity of care and positive client outcomes. Dietician is correct. Dieticians have expertise related to dietary contributions to maintaining health and treating disease and can offer the team suggestions that promote wound healing and muscle repair. The dietician should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation. Physical therapist is correct. Physical therapists have expertise related to the musculoskeletal system and implements therapeutic treatments that will rebuild and improve strength, teach new skills, and regain mobility. The physical therapist should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation. Hospice nurse is incorrect. Hospice nurses have expertise related to palliative care and death and dying. Because the client's condition is not terminal, the hospice nurse should not be involved in the interdisciplinary team meeting. Social worker is correct. Social workers have expertise in working with clients and families to resolve issues that arise due to health problems and can link the client with community resources, assist with developing the discharge plan, and resolve conflict. The social worker should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation. Respiratory therapist is incorrect. Respiratory therapists have expertise related to therapeutic procedures and treatments for clients who have respiratory difficulties, such as oxygen therapy, inhalation therapy, administering pulmonary function tests, collection of sputum specimens, and collection of arterial and venous blood specimens. Because the client does not have any respiratory difficulties, the respiratory therapist should not be involved in the interdisciplinary team meeting.

A nurse is caring for a client who has a fractured hip and respiratory rate of 26/min. Which of the following actions should the nurse take first? A) Evaluate level of consciousness. B) Place the client on bed rest. C) Encourage increased fluid intake. D) Initiate continuous ECG monitoring.

A) Evaluate level of consciousness. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client so a plan of care can be developed. Clients who have a fractured hip are at risk for fat embolism syndrome because of the release of fat globules from the yellow bone marrow. These globules enter the blood stream where they can travel and occlude small vessels and impair perfusion to vital organs, including the lungs. A change in the level of consciousness is the earliest manifestation of fat embolism syndrome. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care. This option is further supported by the ABC priority setting framework.

A newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are in which of the following categories during a disaster? A) Immediate B) Delayed C) Minimal D) Expectant

A) Immediate Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client with injuries that are severe, but has the potential to survive with treatment. Clients assigned to the immediate triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received. Based on the survival potential priority setting framework, the nurse should provide priority care to clients in this category.

A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first? A) Initiate a bladder training schedule. B) Administer solifenacin (Vesicare). C) Insert an indwelling urinary catheter. D) Perform intermittent catheterization.

A) Initiate a bladder training schedule. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Bladder retraining is a restorative care method used with clients who have urinary incontinence. Based on the least restrictive, least invasive priority setting framework, this is the first action the nurse should take.

A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions? A) Lithotomy B) Dorsal recumbent C) Prone D) Lateral recumbent

A) Lithotomy The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia. The nurse should drape the client appropriately to minimize exposure and embarrassment.

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor? A) Maternal respirations B) Fetal heart rate C) Maternal deep-tendon reflexes D) Maternal urinary output

A) Maternal respirations Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs and the fetus via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are priority concerns of the nurse caring for a client who is in preterm labor and is receiving magnesium sulfate. Excessive levels of magnesium can suppress neuromuscular transmission, placing the client at risk for respiratory depression. Based on this knowledge and using the ABC priority setting framework, it is most important for the nurse to monitor maternal respirations.

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? A) Obtain an ECG. B) Administer oral potassium. C) Encourage potassium-rich foods. D) Monitor I & O.

A) Obtain an ECG. Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range. According to Maslow's Hierarchy of Needs priority setting framework, physiological needs, such as adequate cardiac functioning, receive highest priority. This action is further supported by the ABC priority setting framework due to the impact of cardiac function on circulation.

A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? A) Place the infant in a supine position when sleeping. B) Place the infant on a firm mattress when sleeping. C) Avoid covering the infant with loose bedding while sleeping. D) Avoid leaving stuffed animals in the crib with the sleeping infant.

A) Place the infant in a supine position when sleeping. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Evidence-based practice and current recommendations of the American Academy of Pediatrics include positioning the infant supine while sleeping. This intervention has had the greatest impact on reducing the occurrence of SIDS. Using the safety and risk reduction priority setting framework and nursing knowledge, this is the priority information to include in the discharge teaching.

A nurse is caring for a child who has leukemia and is prescribed a treatment of platelets. Which of the following should the client experience as a result of the transfusion? A) Reduced bleeding time B) Decreased plasma globulins C) Improved activity tolerance D) Increased immune functioning

A) Reduced bleeding time The content of this question emphasizes the concept of safety through an understanding of the purpose of a platelet transfusion. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating expected therapeutic outcomes, nurses are better able to evaluate treatment effectiveness, which is essential in preventing or minimizing physical or psychological harm to the client. Platelets are responsible for triggering the process of blood clotting. In response to intrinsic factors, such as abnormal blood, or extrinsic factors, such as inflammation or damage to blood cells because of trauma, platelets form platelet plugs. The formation of a platelet plug then triggers the more formal process of blood coagulation. Clients who have leukemia are prone to bleeding because of low platelet counts and should, therefore, experience a reduced bleeding time as a result of a transfusion of platelets.

A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching? A) States that pain is an 8 on a scale of 0 to 10 B) States that her partner should be given the information C) Expresses concern about the exercises causing pain when performed after surgery D) Expresses uncertainty about the benefits of the exercises

A) States that pain is an 8 on a scale of 0 to 10 The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client indicates the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. A key principle of teaching and learning is to first determine the client's readiness and ability to learn. Physical symptoms, such as pain, fatigue, or anxiety, can prevent the client from learning because of a reduced ability to focus on and participate in education.

A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective? A) Toast with peanut butter B) Apple juice C)Yogurt with fresh fruit D) Beef broth

A) Toast with peanut butter In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and manifests as a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations. Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some foods and includes others as appropriate food choices reduces the occurrence and severity of dumping syndrome. Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome.

A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first? A) A client 48 hr following abdominal surgery with redness and swelling at the edges of the incision B) A client following knee replacement surgery complaining of pain and warmth in the calf C) A client admitted with cholecystitis who reports frequent nausea and vomiting D) A client admitted with a GI bleed receiving packed RBCs for hemoglobin of 7.8 gm/dL

B) A client following knee replacement surgery complaining of pain and warmth in the calf Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten the client's survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option describes the most unstable client. Thromboembolism is a potentially serious complication after joint surgeries, particularly those involving the lower extremities. Pain, warmth, and redness are all potential clinical manifestations of a thromboembolism, which can lead to the development of a pulmonary embolism. Based on the unstable versus stable priority setting framework and nursing knowledge, this is the client the nurse should evaluate first.

A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit? A) Obtain an arterial pH level. B) Check the heart rate and blood pressure. C) Insert an indwelling catheter. D) Collect a serum BUN and creatinine.

B) Check the heart rate and blood pressure. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. An increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit. Using the least restrictive, least invasive priority setting framework, this action is less invasive than the other actions and should be the nurse's first action.

A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following actions should the nurse take? A) Administer an anticoagulant. B) Check the leg for warmth and edema. C) Apply elastic stockings. D) Promote bed rest and extremity elevation.

B) Check the leg for warmth and edema. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. If warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep-vein thrombosis. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse in a long-term facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? A) Provide assistance with ambulation when indicated. B) Determine the mobility status of each client. C) Maintain the side rails of each bed in the raised position. D) Plan a fall prevention program for clients at risk.

B) Determine the mobility status of each client. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Determining the mobility status of each client will help to identify those patients who are at risk for falls. This knowledge will ensure the implementation of education and prevention efforts specific to the needs of each client. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? A) Lithium carbonate 0.8 mEq/L B) Digoxin 3.0 ng/mL C) Peak serum gentamicin 6 mcg/mL D) Magnesium sulfate 4 mEq/L

B) Digoxin 3.0 ng/mL Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients get priority because of needs that threaten their survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option poses the greatest risk to the client. This digoxin level is above the expected reference range and indicates digoxin toxicity. Based on the unstable versus stable priority setting framework and nursing knowledge, this lab value is the priority and should be immediately reported to the provider.

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis. A) Increased appetite B) Elevated temperature C) Bradycardia D) Drowsiness

B) Elevated temperature The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The identification of expected and unexpected findings associated with a client's diagnosis assists the nurse to distinguish possible unrelated complications the client might be experiencing, which indicates the need for further investigation. The specific focus on the client enhances the provision of safe, quality nursing care. An elevated temperature is a finding associated with acute alcohol delirium.

A nurse is caring for a client who has a radial head fracture. Which of the following should be the priority action of the nurse following application of the cast? A) Promote adequate intake of calcium. B) Evaluate neurovascular status. C) Elevate the extremity above the heart. D) Apply ice intermittently for the first 24 hr.

B) Evaluate neurovascular status. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Neurovascular compromise is a manifestation of compartment syndrome and must be detected in the early stages to avoid permanent damage. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care. This action can be further supported as the priority action using the ABC priority setting framework.

A nurse is caring for a client who has difficulty breathing. Which of the following actions should the nurse take first? A) Place O2 at 2 L per nasal canula on the client. B) Place the client in the orthopneic position. C) Perform chest percussion. D) Perform nasotracheal suctioning.

B) Place the client in the orthopneic position. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort. Based on the least restrictive, least invasive priority setting framework, this should be the first action the nurse takes.

A nurse is reviewing lab results for four clients. The client with which of the following values requires immediate intervention? A) Cholesterol 220 mg/dL B) Platelets 95,000 mm3 C) BUN 20 mg/dL D) Potassium 3.5 mEq/L

B) Platelets 95,000 mm3 Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten their survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option poses the greatest risk to the client. This platelet level is below the expected reference range and indicates the client is at risk for bleeding. Based on the stable versus unstable priority setting framework and nursing knowledge, the client with this laboratory value requires immediate intervention.

A school nurse is reinforcing teaching regarding bicycle safety to a group of school-age children. Which of the following is the most important concept to include in the teaching? A) Place proper lights and reflectors on the bicycle. B) Use a properly-fitted bicycle helmet. C) Wear light-colored clothing at night. D) Use hand signals when turning.

B) Use a properly-fitted bicycle helmet. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It can be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. A properly-fitted bicycle helmet should always be worn to prevent head injuries. Using the safety and risk reduction priority setting framework and nursing knowledge, the greatest risk to the client is blunt trauma to the head. Because adequate brainstem functioning is required to support breathing and circulation, this option is further supported by the ABC priority setting framework.

A nurse is caring for a toddler with acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops? A) Place the child on the affected side for several minutes upon completion of instillation. B) Warm refrigerated drops to room temperature prior to instillation. C) Pull the pinna of the ear upward and back during instillation. D) Massage the area posterior to the ear after instillation.

B) Warm refrigerated drops to room temperature prior to instillation. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is an appropriate action by the nurse when administering ear drops. Ear drops are topically administered medications, which are slowly absorbed through the skin and primarily provide local results. Because of the anatomy of internal ear structures, it is important to remember that the ear is sensitive to extremes in temperature. Ear drops should be warmed to room temperature prior to instillation to reduce the risk of painful stimuli.

A nurse is reinforcing teaching about client consent to a treatment with a group of newly licensed nurses. Which of the following statements made by a newly licensed nurse indicates a need for further teaching? A) "It is necessary to have written consent for invasive procedures." B) "Implied consent is appropriate for some aspects of nursing care." C) "It is the responsibility of the provider to obtain express consent." D) "Informed consent should be obtained separately for each surgical procedure."

C) "It is the responsibility of the provider to obtain express consent." The content of this question emphasizes the concept of professionalism by ensuring understanding of the legal concept of consent. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching.

A nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective? A) "I should leave the patch on for 16 to 20 hours each day." B) "I will apply a new patch in the same location each day." C) "The patch should be effective within an hour of being applied." D) "The medication is not absorbed as well when placed on the abdomen."

C) "The patch should be effective within an hour of being applied." The content of this question emphasizes the concept of client education by evaluating teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching be an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This statement by the client is true and indicates teaching has been effective. Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.

A nurse working the 7 pm to 7 am shift on the pediatric unit has received report on four postoperative clients. Which of the following requires immediate intervention? A) An adolescent who is postoperative following an appendectomy and has refused to ambulate for the past 8 hr B) A school-age child who is postoperative following a herniorrhaphy with an infiltrated peripheral IV that has been clamped C) A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing D) An infant who is postoperative following a cleft palate repair with a heart rate of 146/min and a respiratory rate of 28/min

C) A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients get priority because of needs that threaten the client's survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option describes the most unstable client. A preschooler who is experiencing frequent swallowing following a tonsillectomy could be bleeding, placing the client at risk for hemorrhage. Bleeding from the surgical site can cause the dripping of blood down the back of the throat, which results in frequent swallowing or clearing of the throat and indicates the client could be unstable. Based on the unstable versus stable priority setting framework and nursing knowledge, the client requires immediate intervention. This option is further supported by the ABC priority setting framework.

A nurse is collecting data on a newborn who was delivered 30 mins ago at the gestational age of 37 weeks. Which of the following findings requires further intervention? A) Vesicular rash B) Respiratory rate 54/min C) Abdominal distension D) Heart rate142/min

C) Abdominal distension In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. Abdominal distension that is present at birth indicates a tumor or an abdominal wall defect, such as a ruptured viscus. This finding should be reported to the provider immediately and evaluated further.

A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality? A) Placement of computer systems in restricted areas B) Installation of firewall software on each computer C) Ability of staff to access electronic health records of clients throughout the facility D) Occurrence of an automatic log-off after a period of inactivity

C) Ability of staff to access electronic health records of clients throughout the facility Ability of staff to access electronic health records of clients throughout the facility MY ANSWER The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology. In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is not appropriate and can result in a violation of client confidentiality. The ability of staff to access electronic health records of clients throughout the facility allows for viewing confidential information on clients the staff might not directly be involved in the care of. The majority of staff should only be allowed to access the electronic health records of clients on the unit where he or she works.

A nurse is caring for a client who is 48 hr postoperative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? A) Absent bowel sounds B) Serum BUN level 22 mg/dL C) Absent dorsalis pedis pulses D) Serum creatinine level of 1.3 mg/dL

C) Absent dorsalis pedis pulses Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is absent dorsalis pedis pulses. Absence of these pulses indicates that a graft occlusion following an abdominal aortic aneurysm repair is blocking circulation. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the most urgent need. This option is further supported by the ABC priority setting framework.

A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first? A) Administer an analgesic. B) Assist the client to shift positions. C) Check pedal pulse. D) Distract the client with music therapy.

C) Check pedal pulse. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Pressure on the peroneal nerve can occur when skin traction is applied to lower extremities, which can result in foot drop. This can be manifested as a burning sensation under the traction bandage or boot. Reduced circulatory impairment can also result in the sensation of pain. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is caring for an older adult client who recently experienced death of her partner. Which of the following is the priority need of the client? A) Establishing a sense of achievement B) Contributing to society C) Creating meaningful social relationships D) Enhancing self-confidence

C) Creating meaningful social relationships Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The third level of Maslow's Hierarchy of Needs includes love, affection, and social relationships in fulfilling love and belonging needs. Social relationships are a component of friendship, which would be included in the third level of Maslow's Hierarchy of Needs. Based on Maslow's Hierarchy of Needs, this is the client's priority need.

A nurse is in a local clinic caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client? A) Mammogram every year to detect breast cancer B) Colonoscopy every 10 years to detect colon cancer C) Dermatologist evaluation every 3 years to detect skin cancer D) Complete eye examination every year to detect eye disorders

C) Dermatologist evaluation every 3 years to detect skin cancer The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A dermatologist evaluation every 3 years is an appropriate screening to recommend to a 35-year-old client. Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations. Note: Women ages 40 or older should have annual mammograms.

A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take? A) Administer epinephrine (Adrenaline). B) Elevate the lower extremities. C) Determine respiratory status. D) Apply oxygen via non-rebreather mask.

C) Determine respiratory status. The content of this question emphasizes the concept of priority setting by determining priority nursing action for a client experiencing an allergic reaction. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This item can be answered using both nursing process and the ABC priority setting framework. The client is experiencing angioedema, indicating the possibility of an anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status.

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice? A) Assign a security guard to stay at the client's door. B) Request a prescription from the provider for soft restraints. C) Discuss the risks associated with leaving with the client. D) Remove the telephone from the client's room.

C) Discuss the risks associated with leaving with the client. The content of this question emphasizes the concept of professionalism by determining the legal actions of the nurse when a client leaves a facility against medical advice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Discussing the risks associated with leaving the facility against medical advice with the client is a priority concern. The client should be made aware of potential negative outcomes that could occur if he chooses to leave the facility prior to physician-prescribed discharge.

A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication? A) Hypothermia B) Polyuria C) Headache D) Seizures

C) Headache To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Lumbar punctures are performed to withdraw cerebrospinal fluid found in the subarachnoid space for analysis. This is accomplished by inserting a needle into the lumbar subarachnoid space, typically between the third and fourth or fourth and fifth lumbar vertebrae. After the cerebrospinal fluid specimen has been removed, it is not uncommon for leakage of cerebrospinal fluid to continue at the puncture site. The leakage of cerebrospinal fluid leads to insufficient cerebrospinal fluid in the brain, which causes an inability to maintain appropriate mechanical stabilization of the brain. A headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture that results from cerebrospinal fluid leakage at the puncture site. These headaches are managed primarily with analgesics, hydration, and bed rest.

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of bethamethasone (Celestone). Because of the administration of the bethamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? A) Tachycardia B) Sternal retractions C) Hypoglycemia D) Hypothermia

C) Hypoglycemia The content of this question emphasizes the concept of safety through the recognition of a potential adverse effect that can result in physical harm. Safety in nursing practice is the minimization of risk factors that can cause harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern? A) Facial abrasions B) Penetrating head wound C) Incomplete amputation of the foot D) Tibia fracture requiring open reduction

C) Incomplete amputation of the foot Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client who has injuries that are severe, but has the potential to survive with treatment. A client with an incomplete amputation of the foot should be assigned to the immediate triage category because injuries are life-threatening, but survivable if immediate care is received. The nurse should place highest priority on this client.

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A) Pupil dilation B) Ataxia C) Lethargy D) Bradycardia

C) Lethargy The content of this question emphasizes the concept of safety through the identification of an initial manifestation of increased ICP. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating potential complications, nurses are better able to predict a needed intervention, which assists in preventing or minimizing physical or psychological harm to the client. Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in the level of consciousness, such as restlessness, irritability, and disorientation, lethargy is the first sign of increased ICP. Note: Ataxia, which is a loss of balance, occurs with brainstem or cerebellar injuries; however, this is a later sign of increased ICP.

A nurse is caring for a client who is in the immediate postoperative period following a tracheostomy. Which of the following is the nurse's priority action? A) Providing pain control B) Preventing hemorrhage C) Maintaining a patent airway D) Ensuring adequate fluid intake

C) Maintaining a patent airway Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating that oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway is the nurse's priority action for a client who is in the immediate postoperative period following a tracheotomy. An airway obstruction is a potential complication for clients following head and neck surgery secondary to production of mucus and need for suctioning. Based on this knowledge and using the ABC priority setting framework, the nurse's priority action is to maintain a patent airway.

A nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the action of the nurse? A) Administer nebulized epinephrine (racemic epinephrine). B) Ensure adequate hydration. C) Obtain an oxygen saturation level. D) Encourage parents to comfort the client.

C) Obtain an oxygen saturation level. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Laryngotracheobronchitis can result in impaired airway clearance because of upper airway swelling and increased respiratory effort. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is caring for a client who was admitted to the unit 3 hrs ago following a hip arthroplasty. Which of the following findings should be the nurse's priority concern? A) Urinary output of 75 mL over the past 3 hr B) 8-point elevation in the pre-surgery diastolic blood pressure C) Oxygen saturation of 90% on oxygen at 2 L per nasal cannula D) Core body temperature of 36.2° C (97.2° F)

C) Oxygen saturation of 90% on oxygen at 2 L per nasal cannula Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is an oxygen saturation of 90% on oxygen at 2 L per nasal cannula. Hypoxemia can be caused by a number of potentially life-threatening conditions in the postoperative period, such as atelectasis, pulmonary edema, or pulmonary embolism. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the nurse's priority concern.

A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? A) Homelessness B) Lack of family support C) ​Hypoxic D) Under nourished

C) ​Hypoxic When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level of Maslow's Hierarchy of Needs. Because oxygen is considered the most basic physiological need, this is the need the nurse should address first. This is further supported using the ABC priority setting framework.

A nurse is caring for a client who has a new colostomy. The client is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughters states that she doesn't know how she is going to care for her mother's colostomy? A) "It's quite simple. I'll make sure that her colostomy bag is clean before she leaves and you'll have no problems." B) "Is the colostomy care the only reason your mother is going to be living with you?" C) "A home health nurse will be stopping by tomorrow. If you have any questions, you can ask her." D) "What part of your mother's care concerns you?"

D) "What part of your mother's care concerns you?" In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Clarification encourages the other person to further express concerns so they can be addressed. This is an appropriate response by the nurse because it uses the communication tool of clarification.

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? A) A client who has peripheral vascular disease and reports numbness in the toes B) A client who has depression and is easily distracted C) A client who has Alzheimer's disease and is unable to complete activities of daily living D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop

D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Wound dehiscence or evisceration most commonly occurs 3 to 11 days following surgery and can be caused by not splinting the surgical site when moving, forceful coughing, vomiting, or straining. Clients often report feeling the incision "pop," indicating either dehiscence or evisceration has occurred. Based on the acute versus chronic priority setting framework, the nurse should evaluate this client first.

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A) A client who has COPD with an oxygen saturation of 90% B) A client who has diabetes mellitus with a HbA1C of 9% C) A client who has heart failure with 2+ pitting edema of the lower extremities D) A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant

D) A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Nursing knowledge might also be needed to determine which option describes an acute need. Heart failure is a chronic condition that results in fluid volume excess because of reduced cardiac output. A fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant is an acute finding that indicates possible appendicitis. Based on the acute versus chronic priority setting framework, this is the client the nurse should evaluate first.

A nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should the nurse's priority concern? A) A client who is 26 weeks of gestation and reporting leukorrhea B) A client who is 10 weeks of gestation and reporting urinary frequency C) A client who is 37 weeks of gestation and reporting perineal discomfort D) A client who is 34 weeks of gestation and reporting abdominal tenderness

D) A client who is 34 weeks of gestation and reporting abdominal tenderness Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients get priority because of needs that threaten the client's survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option describes the most unstable client. Abdominal, or uterine tenderness, is an early clinical finding associated with abruption placenta, which could lead to an unstable status. Based on the unstable versus stable priority setting framework and nursing knowledge, this is the client that should be the nurse's priority concern.

A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? A) A client who has a history of heart failure B) A client who has type 1 diabetes mellitus C) A client who is reporting pain associated with osteoarthritis of the knees D) A client who is having a nosebleed associated with hypertension

D) A client who is having a nosebleed associated with hypertension Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase - so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. A nose bleed, or epistaxis, is an acute condition requiring immediate intervention to prevent further blood loss. Additionally, this finding can be associated with a blood pressure that is above the expected reference range, indicating the need for further intervention. Based on the acute versus chronic priority setting framework, this client should be the nurse's priority.

A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention? A) A client who has cystic fibrosis and has a paroxysmal cough B) A client who is prescribed cromolyn sodium (Crolom) and has a peak expiratory flow rate of 79% C) A client who has celiac disease and abdominal distention. D) A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting

D) A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Nursing knowledge might also be needed to determine which option describes an acute need. Vomiting, slow heart rate, and anorexia are clinical findings associated with digoxin toxicity, which is an acute condition. Based on the acute versus chronic priority setting framework, this is the client that requires immediate intervention.

A nurse is caring for a patient who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in the discussion with the patient? A) Acupuncture is loosely regulated by the federal government. B) Acupuncture has been discredited by scientific research. C) Acupuncture is thought to be effective only as a placebo. D) Acupuncture has been proven to reduce pain and increase function.

D) Acupuncture has been proven to reduce pain and increase function. The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should include this information in discussions with the client. Acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies. Clinical research has also shown additional benefits of acupuncture, such as improving memory and orientation among clients who have certain types of dementia.

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign? A) A preschooler with a hip spica cast who is being discharged today B) An infant scheduled for a surgical repair of a ventricular septal defect tomorrow C) A toddler with a fractured femur who has been in Bryant's traction for 5 days D) An adolescent who is 2 days postoperative following an appendectomy

D) An adolescent who is 2 days postoperative following an appendectomy The content of this question emphasizes the concept of leadership through the coordination of client care by making appropriate assignments. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. When making assignments, a leader should effectively communicate and have knowledge of the skill sets of team members in order to ensure clients receive care by the most appropriate person on the team. The care of an adolescent who is 2 days postoperative following an appendectomy requires postoperative care including education, infection prevention, and medications that require fundamental nursing skills and knowledge; therefore, it is appropriate to assign this client to the nurse who has floated from the labor and delivery unit.

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? A) Initiate oxygen therapy. B) Encourage an increase in oral fluids. C) Provide room humidification. D) Assist client to cough effectively.

D) Assist client to cough effectively. Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Assisting the client to cough effectively opens the airway by removing secretions. Based on the ABC priority setting framework, this is the first action the nurse should take because a clear airway is necessary for oxygen exchange to occur.

A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, " I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help with my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following? A) Celecoxib is contraindicated in clients taking valproic acid. B) Celecoxib is contraindicated in older adults. C) Celecoxib is contraindicated in clients with a seizure disorder. D) Celecoxib is contraindicated in clients with an allergy to sulfonamide.

D) Celecoxib is contraindicated in clients with an allergy to sulfonamide. The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore, celecoxib is contraindicated in clients who have an allergy to sulfa.

A nurse is taking care of an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it to see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following: A) Celecoxib is contraindicated in clients taking valproic acid. B) Celecoxib is contraindicated in older adults. C) Celecoxib is contraindicated in clients with a seizure disorder. D) Celecoxib is contraindicated in clients with an allergy to sulfonamide.

D) Celecoxib is contraindicated in clients with an allergy to sulfonamide. The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore, celecoxib is contraindicated in clients who have an allergy to sulfa.

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor? A) Diplopia B) Loss of bladder control C) Paresthesias D) Decreased respiratory effort

D) Decreased respiratory effort Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are priority concerns of the nurse caring for a client who has myasthenia gravis. Myasthenia gravis affects neuromuscular transmission of the voluntary muscles of the body. Progressive weakness of the diaphragmatic and intercostal muscles can produce respiratory distress. Based on this knowledge and using the ABC priority setting framework, it is most important for the nurse to monitor for respiratory difficulty

A nurse is reinforcing teaching about performing suctioning to a client who has been discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that the teaching has been effective? A) Self-reporting the ability to perform the procedure B) Answering appropriately when questioned orally C) Responding accurately on a written examination D) Demonstrating independent performance of the procedure

D) Demonstrating independent performance of the procedure The content of this question emphasizes the concept of client education by determining the best indicator of teaching effectiveness. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This is the best indicator of teaching effectiveness. Return demonstration is the best evaluation tool for psychomotor learning, which is the acquisition of knowledge or skills that integrate mental and muscular activity.

A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? A) Malaise B) Anorexia C) Headache D) Diarrhea

D) Diarrhea Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining circulation is the nurse's priority concern. Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume. Based on this knowledge and using the ABC priority setting framework, this is the highest priority finding by the nurse.

A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? A) Administer an anti-anxiety medication. B) Take the client to a place of seclusion. C) Obtain an order for soft wrist restraints. D) Engage the client in physical activity.

D) Engage the client in physical activity. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. Physical or chemical restraints should only be used when the safety of the client, staff, or others is at risk. Gross motor activities can reduce tension and lower anxiety levels. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than others and should be the first action of the nurse.

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication? A) Hyperkalemia B) Severe diarrhea C) Atelectasis D) Excessive vomiting

D) Excessive vomiting The content of this question emphasizes the concept of safety through the identification of a specific manifestation that can lead to metabolic alkalosis. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating potential complications, nurses are better able to predict a needed intervention, which assists in preventing or minimizing physical or psychological harm to the client. Metabolic alkalosis is a potential complication of excessive vomiting because of the loss of acid from the body. Note: Metabolic alkalosis is not a potential complication of hyperkalemia, an elevated potassium level, severe diarrhea, or atelectasis, which is an obstruction of the small airways.

A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? A) Administer medications with meals when possible. B) Ensure client understanding of medication's effects. C) Determine the client's ability to self-administer medications. D) Have the client position the head with the chin down while swallowing.

D) Have the client position the head with the chin down while swallowing. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Clients are at risk for aspiration following a CVA, and having the client position the head with the chin down while swallowing reduces this risk. Based on the safety and risk reduction priority setting framework, this should be the nurse's priority action. Preventing aspiration is further supported as the priority by the ABC priority setting framework.

A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client? A) Raising her voice level when speaking to the client B) Asking the client open-ended questions C) Clarifying client statements with the family as needed D) Having the client use eye blinks to indicate yes or no

D) Having the client use eye blinks to indicate yes or no Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Having a client who has aphasia use eye blinks to indicate yes or no is an appropriate action by the nurse. This action reduces anxiety of the client, allows for appropriate communication, and reduces the risk for miscommunication.

A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? A) Ensure all four side rails are up. B) Administer a prescribed sedative. C) Place the client in soft wrist restraints. D) Move the client to a room near the nurses' station.

D) Move the client to a room near the nurses' station. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using physical restraints. Physical restraints should only be used when the safety of the client, staff, or others is at risk. Moving the client to a room near the nurses' station allows for more frequent observation and promotes client safety. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than the other actions and should be the nurse's first action.

A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at an increased risk for hypokalemia? A) Nephrostomy tube to drainage bag B) Indwelling catheter to gravity C) Chest tube to water seal D) NG tube to suction

D) NG tube to suction To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. Hypokalemia refers to a depletion of potassium and can result from a reduction in total potassium stores or from a temporary shift of extracellular potassium into the cell. Reductions in total potassium are caused by medications, such as diuretics, digitalis, and corticosteroids; Cushing's syndrome; diarrhea; vomiting; and wound drainage among others. Reductions in extracellular potassium caused by potassium shifting back into cells result from alkalosis, hyperinsulinism, total parenteral nutrition, and water intoxication among others. Intestinal suctioning through an NG tube results in the loss of gastric fluids. Potassium exists in large amounts in the GI fluids and is lost when gastric fluids are lost. This client is at an increased risk for hypokalemia.

A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal? A) Support the client's relationship with his caregivers. B) Encourage the client to express his feelings. C) Determine who is responsible for the abuse. D) Protect the client from further abuse.

D) Protect the client from further abuse. The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. Protecting the client from further abuse should be the nurse's priority goal, as failure to do so can result in additional harm to the client. Maslow's Hierarchy of Needs states that if there is not a physiological need, then safety needs must be considered first. Because the client has been hospitalized for 3 days, physiological needs have most likely been taken care of; therefore, the nurse should act to keep the client safe from harm.

A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis? A) Tuberculin test B) Chest x-ray C) Enzyme-linked immunoassay (ELISA) test D) Sputum culture for acid-fast bacillus

D) Sputum culture for acid-fast bacillus In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis, which is an airborne organism. Once infected, the bacteria multiply freely after reaching the bronchi or alveoli. Typically, acquired immunity protects individuals from attaining active tuberculosis. Infection is most common among those who are immunocompromised and those who have been in repeated, close contact with someone who has an undiagnosed case of active tuberculosis. The lungs are primarily involved, but the infection can spread to other organs. Symptoms of pulmonary tuberculosis include productive cough, fever, fatigue, weight loss, hemoptysis, and night sweats. In cases of active pulmonary tuberculosis, the organism is transmitted through the air because it is found in the sputum and secretions. The presence of acid fast bacillus in the sputum, secretions, or tissues of the client is the only method to confirm the diagnosis of active tuberculosis.