Basics of Nursing Practice

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client's room. How should the nurse respond to the technician? 1."I can't receive them right now. Please wait a few minutes or come back." 2."Please leave the medications and sign-out sheet in a location where I can see them." 3."Please bring them to me and I will be sure to put them away in a couple of minutes." 4."I can't receive them right now. Please give them to the unlicensed assistive personnel (UAP)."

1."I can't receive them right now. Please wait a few minutes or come back."

A nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." How should the nurse respond? 1."Your wish will be respected." 2."Why do you want to be called Doctor?" 3."Residents here call one another by their first names." 4."Wouldn't it be better if the others do not know you are a doctor?"

1."Your wish will be respected."

A client with cancer is informed that the chemotherapy is no longer working and that death is inevitable. Keeping in mind Kübler-Ross's stages of death and dying, place the following nursing interventions that are most appropriately associated with each stage in order from the stage of denial to acceptance. 1.Provide maximal comfort measures 2.Redirect negative feelings constructively. 3.Help the client identify realistic versus unrealistic goals. 4.Avoid confronting the client. 5.Help the client celebrate the simple pleasures in everyday life

1.Avoid confronting the client. 2.Redirect negative feelings constructively. 3.Help the client identify realistic versus unrealistic goals. 4.Help the client celebrate the simple pleasures in everyday life 5.Provide maximal comfort measures.

A client who has been battling cancer of the ovary for seven years is admitted to the hospital in a debilitated state. The health care provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? 1.Sit down quietly next to the bed and allow her to cry. 2.Pull the curtain and leave the room to provide privacy for the client. 3.Explain to the client that her feelings are expected and they will pass with time. 4.Observe the length of time the client cries and document her difficulty accepting her impending death

1.Sit down quietly next to the bed and allow her to cry.

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer? 1.The client should have been turned regularly. 2.Older clients frequently develop pressure ulcers. 3.The nurse is not responsible to the client's family. 4.Nurses should respect a client's right not to be moved

1.The client should have been turned regularly.

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection: 1.To the client from outside sources. 2.From the client to others. 3.From the client by using special techniques to destroy infectious fluids and secretions. 4.To the client by using special sterilization techniques for linens and personal items.

1.To the client from outside sources.

What are the best ways for a nurse to be protected legally? (Select all that apply.) 1.Ensure that a therapeutic relationship with all clients has been established. 2.Provide care within the parameters of the state's nurse practice act. 3.Carry at least $100,000 worth of liability insurance. 4.Document consistently and objectively. 5.Clearly document a client's non-adherence to the medical regimen.

2.Provide care within the parameters of the state's nurse practice act. 4.Document consistently and objectively. 5.Clearly document a client's non-adherence to the medical regimen.

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? 1."I should carry objects about 18 inches from my body." 2."I should sleep on my stomach with a firm mattress." 3."I should carry objects close to my body." 4."I should pull rather than push when moving heavy objects."

3."I should carry objects close to my body."

A home health nurse checks the client's vital signs and completes a follow- up visit. After completion of these tasks, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? 1."I would, but my back hurts today." 2."Okay. It will be my good deed for the day." 3."Of course. I want to do whatever I can for you." 4."I would like to, but it is not in my job description."

3."Of course. I want to do whatever I can for you."

Which nursing behavior is an intentional tort? 1.Miscounting gauze pads during a client's surgery. 2.Causing a burn when applying a wet dressing to a client's extremity. 3.Divulging private information about a client's health status to the media. 4.Failing to monitor a client's blood pressure before administering an antihypertensive

3.Divulging private information about a client's health status to the media.

A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action? 1.Notify the health care provider. 2.Report this to the nurse manager. 3.Tell the client that the cigarettes were found. 4.Discard the cigarettes without commenting to the client.

3.Tell the client that the cigarettes were found.

While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as: 1.malignant hypotension 2.orthostatic dehydration 3.orthostatic hypotension 4.vasomotor instability

3.orthostatic hypotension

Several recently licensed practical nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance? 1."If you have liability insurance, you are more likely to be sued." 2."Your employer provides you with the liability insurance you will need." 3."Liability insurance is not available for nursing professionals working in a hospital." 4."Personal liability insurance offers representation if the State Board of Nursing files charges against you."

4."Personal liability insurance offers representation if the State Board of Nursing files charges against you."

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? 1.Obtain the vital signs. 2.Notify the health care provider. 3.Reinsert the protruding organs using aseptic technique. 4.Cover the wound with a sterile towel moistened with normal saline.

4.Cover the wound with a sterile towel moistened with normal saline.

The professional obligation of a nurse to assume responsibility for actions is referred to as: 1.Accountability. 2.Individuality. 3.Responsibility. 4.Bioethics

1.Accountability

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? 1.Decreased blood supply 2.Impaired neural functioning 3.Perforation of the bowel wall 4.Obstruction of the bowel lumen

2.Impaired neural functioning

A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that the legal term that best describes this situation is: 1.False threats 2.Assault and battery 3.False imprisonment 4.Breach of confidentiality

3.False imprisonment

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? 1.Heredity 2.Hypertension 3.Cigarette smoking 4.Diabetes mellitus

1.Heredity

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted? 1.These actions can be construed as assault and battery. 2.The problem was resolved with forethought and accountability. 3.Skin must be protected, and the actions taken were by a reasonably prudent nurse. 4.The nurse had tried to reason with the toddler and expected understanding and cooperation.

1.These actions can be construed as assault and battery.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? 1.Hepatitis C (HepC) 2.Influenza type B (HIB) 3.Measles, mumps, rubella (MMR) 4.Diphtheria, tetanus, pertussis (DTaP)

3.Measles, mumps, rubella (MMR)

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 1.The dosage is kept at a minimum. 2.Only a small part of the body is irradiated. 3.The client's physical condition is not a risk factor. 4.Nutritional environment of the affected cells is a risk factor.

2.Only a small part of the body is irradiated.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcers? 1.Stage I 2.Stage II 3.Stage III 4.Stage IV

3.Stage III

What should the nurse do initially when obtaining consent for surgery? 1.Describe the risks involved in the surgery. 2.Explain that obtaining the signature is routine for any surgery. 3.Witness the client's signature, which the nurse's signature will document. 4.Determine whether the client's knowledge level is sufficient to give consent

4.Determine whether the client's knowledge level is sufficient to give consent

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? 1.Libel 2.Slander 3.Negligence 4.Invasion of privacy

4.Invasion of privacy

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next: 1.Bending and then straightening their knees 2.Bending at the waist and then straightening the back 3.Placing one foot in front of the other and then leaning back 4.Placing pressure against the client's axillae and then raising their arms

1.Bending and then straightening their knees

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion? 1.Speaking aloud at weekly meetings 2.Promising to attend at least 12 meetings yearly 3.Maintaining controlled drinking after six months 4.Acknowledging an inability to control the problem

4.Acknowledging an inability to control the problem

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is priority nursing intervention to assist the client with compliance with medication-taking? 1.Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2.Develop a chart for the client, listing the times the medication should be taken. 3.Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen. 4.Instruct the client and client's children to put medications in a weekly pill organizer.

3.Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen.

A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take? 1.Notify the nurse manager of the unit. 2.Inform no one because all client information is confidential. 3.Inform the client's healthcare provider. 4.Alert the hospital security department because heroin is an illegal substance

3.Inform the client's healthcare provider.

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? 1.Malice 2.Tort law 3.Malpractice 4.Case law

3.Malpractice

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to: 1.Promote gluconeogenesis. 2.Produce an anti-inflammatory effect. 3.Promote cell growth and bone union. 4.Decrease pain medication requirements.

3.Promote cell growth and bone union.