CBC Practice Exam 4 A

A nurse is teaching a client who has deep-vein thrombosis and is receiving heparin injections. The nurse should instruct the client to report which of the following manifestations as an adverse effect of the medication? A) A decrease in appetite B) A decrease in urinary output C) An increase in sleeplessness D) An increase in nosebleeds

A) A decrease in appetite Rationale: A decrease in appetite is not an adverse effect of heparin. B) A decrease in urinary output Rationale: A decrease in urinary output is not an adverse effect of heparin. C) An increase in sleeplessness Rationale: An increase in sleeplessness is not an adverse effect of heparin. D) An increase in nosebleeds Rationale: The nurse should instruct the client to monitor for and report an increase in nosebleeds or bruising to the provider, as these can be indications of hemorrhage, which is an adverse effect of heparin.

A nurse is working on an interprofessional collaboration plan for care for a client who has stage III pressure ulcer. Which of the following actions should the nurse recognize as the role of the licensed practical nurse? A) Administer pain medication. B) Initiate the plan of care. C) Determine protein needs for the client. D) Prescribe a referral for physical therapy.

A) Administer pain medication. Rationale: The nurse should identify that the administration of pain medicine is within the scope of practice of a licensed practical nurse. B) Initiate the plan of care. Rationale: The nurse should identify that a registered nurse should initiate the plan of care. C) Determine protein needs for the client. Rationale: Determine protein needs for the client. The nurse should identify that determining protein needs for the client is the role of the dietitian. D) Prescribe a referral for physical therapy. Rationale: The nurse should identify that prescribing a referral for physical therapy is the role of the provider.

A nurse is teaching a group of newly licensed nurses about different levels of care. Which of the following should the nurse use as an example of primary care? A) Critical care unit B) Emergency department C) Prenatal care D) Home health care

A) Critical care unit Rationale: A critical care unit is an example of tertiary care. B) Emergency department Rationale: The emergency department is an example of secondary care. C) Prenatal care Rationale: Primary care focuses on preventive care and health education. Prenatal care, nutrition counseling, exercise classes, and immunizations are examples of primary care. D) Home health care Rationale: Home health care provides tertiary care to clients who have a disease or illness that requires medical or assistive services in the home setting.

A triage nurse is prioritizing clients following a mass casualty disaster. Which of the following clients should the nurse treat first? A) A client who has extensive full-thickness burns to 85% of her body B) A client who is exhibiting manifestations of shock C) A client who has an open distal fibula fracture D) A client who has multiple abrasions to the chest and lower extremities

A) A client who has extensive full-thickness burns to 85% of her body Rationale: A client who has extensive full-thickness burns to 85% of her body has a minimal chance of survival, even with intervention. Therefore, the nurse should treat another client first. B) A client who is exhibiting manifestations of shock Rationale: A client who is exhibiting manifestations of shock requires immediate intervention for survival. Therefore, when using the survival approach to client care, the nurse should treat this client first. C) A client who has an open distal fibula fracture Rationale: A client who has an open distal fibula fracture does not have an immediate threat to life and can wait for treatment. Therefore, the nurse should treat another client first. D) A client who has multiple abrasions to the chest and lower extremities Rationale: A client who has multiple abrasions to the chest and lower extremities does not have an immediate threat to life and can wait for treatment. Therefore, the nurse should treat another client first.

A nurse is teaching a client who has HIV about zidovudine. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of this medication? A) Fever B) Hallucinations C) Polyuria D) Constipation

A) Fever Rationale: The nurse should instruct the client to monitor for a fever, which can indicate an infection caused by bone marrow suppression. B) Hallucinations Rationale: The nurse should instruct the client that seizures, rather than hallucinations, are an adverse effect of this medication. C) Polyuria Rationale: The nurse should instruct the client that this medication does not affect kidney function. Therefore, the client does not need to monitor for polyuria. D) Constipation Rationale: The nurse should instruct the client that diarrhea, rather than constipation, is an adverse effect of this medication.

A nurse is assessing a newborn. Which of the following should the nurse identify as a manifestation of sepsis? A) Grunting B) Polyuria C) Acrocyanosis D) Hypertension

A) Grunting Rationale: The nurse should expect a newborn who has sepsis to exhibit grunting, nasal flaring, retractions, apnea, tachycardia, hypotension, lethargy, pallor, petechiae, hypoglycemia, hypotonia, or decreased oxygen saturation. B) Polyuria Rationale: The nurse should expect a newborn who has sepsis to have decreased urinary output due to poor feedings and decreased perfusion. C) Acrocyanosis Rationale: The nurse should expect a newborn who has sepsis to exhibit pallor, jaundice, or petechiae. Acrocyanosis is not a manifestation of sepsis. D) Hypertension Rationale: The nurse should expect a newborn who has sepsis to have hypotension and decreased cardiac output.

A nurse who works on a medical-surgical unit is asked to float to the maternal newborn unit due to short staffing. Which of the following professional organizations protects the nurse if she refuses the assignment? A) Institute of Medicine (IOM) B) American Nurses Association (ANA) C) The Joint Commission (JC) D) National Committee for Quality Assurance (NCQA)

A) Institute of Medicine (IOM) Rationale: The IOM is a Congressional independent organization whose goal is to create safer care environments and decrease client injuries. B) American Nurses Association (ANA) Rationale: The ANA protects registered nurses from instances of unethical, inappropriate, or illegal behavior that places clients in danger or jeopardizes a health care facility. The nurse could place clients at risk when floating to a unit where she is unfamiliar with tasks, policies, and procedures.C) The Joint Commission (JC) Rationale: The JC is a nonprofit organization that accredits health care organizations and programs in the United States. D) National Committee for Quality Assurance (NCQA) Rationale: The NCQA is a nonprofit organization that accredits managed care facilities.

A charge nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to the licensed practical nurse (LPN)? A) Instruct a client who had a cerebrovascular accident about swallowing techniques. B) Monitor the blood pressure of a client following a recent myocardial infarction. C) Ambulate a client who is using a walker for the first time. D) Obtain a blood glucose level from a client who has type 1 diabetes mellitus.

A) Instruct a client who had a cerebrovascular accident about swallowing techniques. Rationale: Instructing a client who had a cerebrovascular accident about swallowing techniques requires teaching, which is not within the scope of practice of the LPN. B) Monitor the blood pressure of a client following a recent myocardial infarction. Rationale: Monitoring the blood pressure of a client following a recent myocardial infarction is not within the scope of practice of the LPN. This task requires nursing judgment. C) Ambulate a client who is using a walker for the first time. Rationale: Ambulating a client who is using a walker for the first time requires teaching, which is not within the scope of practice of the LPN. D) Obtain a blood glucose level from a client who has type 1 diabetes mellitus. Rationale: Obtaining a blood glucose level from a client who has type 1 diabetes mellitus is within the scope of practice of the LPN.

A nurse is developing a plan of care for a client who has a traumatic brain injury after a fall. Which of the following medications should the nurse expect to administer to the client to reduce intracranial pressure? A) Mannitol B) Dexamethasone C) Methylprednisolone D) Phenytoin

A) Mannitol Rationale: The nurse should expect to administer mannitol to decrease intracranial pressure. Mannitol is an osmotic diuretic that decreases cerebral edema. B) Dexamethasone Rationale: Dexamethasone is a glucocorticoid that is not indicated as a treatment for the increase in intracranial pressure related to traumatic brain injury. C) Methylprednisolone Rationale: Methylprednisolone is a glucocorticoid that is not indicated as a treatment for the increase in intracranial pressure related to traumatic brain injury. D) Phenytoin Rationale: Phenytoin is an antiepileptic that might be administered to reduce seizure activity. However, antiepileptics do not decrease intracranial pressure.

A community health nurse is planning a public health presentation aimed at minimizing health care disparities. Which of the following age groups should the nurse identify as the priority for increasing health literacy? A) Older adults B) Middle adults C) Young adults D) Adolescents

A) Older adults Rationale: Evidence-based practice indicates that the nurse should target older adults because this age group has the lowest level of health literacy compared to other age groups. B) Middle adults Rationale: The nurse should promote health literacy among middle adults. However, evidence-based practice indicates that the nurse should prioritize a different age group. C) Young adults Rationale: The nurse should promote health literacy among young adults. However, evidence-based practice indicates that the nurse should prioritize a different age group. D) Adolescents Rationale: The nurse should promote health literacy among adolescents. However, evidence-based practice indicates that the nurse should prioritize a different age group.

A nurse manager is teaching a group of nurses about the Occupational Safety and Health Administration (OSHA). Which of the following information should the nurse include in the teaching? A) Provides fact sheets containing biological agent information for health care providers B) Establishes universal protocols and language for disaster response C) Sets standards for hazardous exposures in the workplace D) Regulates school breakfast and lunch programs

A) Provides fact sheets containing biological agent information for health care providers Rationale: The CDC is the agency that provides fact sheets of biological agent information for health care providers to help identify chemical or biological agents during a terrorist attack. B) Establishes universal protocols and language for disaster response Rationale: The National Incident Management System is responsible for establishing universal protocols and language for disaster response and trains emergency management response personnel. C) Sets standards for hazardous exposures in the workplace Rationale: The nurse manager should include in the teaching that OSHA sets standards for hazardous exposures in the workplace and also sets the objectives for Healthy People 2020 that focus on occupational health. D) Regulates school breakfast and lunch programs Rationale: The Department of Agriculture is responsible for the regulation of school breakfast and lunch programs, food stamps for people in need, and the Women, Infants, and Children (WIC) program.

A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take to minimize the risk for a catheter-related infection? A) Secure the catheter to the client's lower abdomen. B) Cleanse the proximal portion of the catheter with chlorhexidine. C) Apply antibiotic ointment to the perineal area twice daily. D) Evaluate the client daily for the necessity of continued catheterization.

A) Secure the catheter to the client's lower abdomen. Rationale: According to research-based care, the nurse should secure the catheter to the thigh of a female client. Movement of the catheter can cause urethral friction and irritation and increase the client's risk for infection. B) Cleanse the proximal portion of the catheter with chlorhexidine. Rationale: According to research-based care, the nurse should perform daily catheter care with soap and water, washing the client's perineum and proximal portion of the catheter. This will remove pathogens and decrease the risk for infection. C) Apply antibiotic ointment to the perineal area twice daily. Rationale: According to research-based care, the nurse does not need to apply antibiotic ointment to the client's perineal area. Use of these ointments or antiseptic solutions has not demonstrated a reduction of catheter-related infection. D) Evaluate the client daily for the necessity of continued catheterization. Rationale: According to research-based care, the nurse should evaluate the client each day to determine the need for maintaining the catheter. Increased dwelling time increases the client's risk for infection. The nurse should discontinue the catheter as early as possible.

A nurse in a substance use treatment facility is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of fidelity? A) The nurse advocates for equal resources for a client who is uninsured. B) The nurse respects a client's decision to refuse a prescribed nicotine patch. C) The nurse keeps a promise to take a walk outside with a client after group therapy. D) The nurse is truthful with a client about the legal implications of her substance use.

A) The nurse advocates for equal resources for a client who is uninsured. Rationale: The nurse is practicing the ethical concept of justice when she advocates for clients who are uninsured to ensure that they receive equal resources and care. Justice is the concept of fairness for all clients. B) The nurse respects a client's decision to refuse a prescribed nicotine patch. Rationale: The nurse is practicing the ethical concept of autonomy when she respects a client's right to refuse a medication. Autonomy is the concept that a client has the right to make independent, informed decisions about his health and treatment. C) The nurse keeps a promise to take a walk outside with a client after group therapy. Rationale: The nurse is practicing the ethical concept of fidelity when she keeps a promise made to a client. By keeping promises, the nurse fosters a client's sense of trust, which promotes a therapeutic nurse-client relationship. D) The nurse is truthful with a client about the legal implications of her substance use. Rationale: The nurse is practicing the ethical concept of veracity when she is truthful with a client. Veracity is the concept of telling the truth to a client, even when the information might be difficult for a client to accept.

A nurse is discussion the prevention of encephalitis at a community health fair. The nurse should recommend which of the following actions to prevent encephalitis? A) Use insect repellent that contains DEET. B) Take prophylactic antibiotics before dental procedures. C) Receive the hepatitis A vaccine. D) Consider genetic testing for the BRCA 1 gene.

A) Use insect repellent that contains DEET. Rationale: The nurse should identify West Nile virus as a cause of encephalitis. Clients should use an insect repellent that contains DEET when outside to prevent transmission of the West Nile virus from mosquitos. B) Take prophylactic antibiotics before dental procedures. Rationale: Prophylactic antibiotics are advised prior to dental procedures to decrease the risk for infective endocarditis for clients who have a prosthetic heart valve or a history of endocarditis. C) Receive the hepatitis A vaccine. Rationale: The hepatitis A vaccine is recommended for clients who are at risk for hepatitis A. However, hepatitis A is not a cause of encephalitis. D) Consider genetic testing for the BRCA 1 gene. Rationale: Genetic testing for the BRCA 1 and BRCA 2 genes is considered for clients who are at risk for breast cancer.

A nurse is assessing a client who has thrombocytopenia. Which of the following findings should the nurse expect? A) Platelets 130,000/mm3 B) Peripheral edema C) RBC 5.1 million/mm3 D) Swollen lymph nodes

A) Platelets 130,000/mm3 Rationale: The nurse should expect the client to have a decreased platelet count. This finding is below the expected reference range. B) Peripheral edema Rationale: The nurse should expect a client who has heart failure to have peripheral edema. C) RBC 5.1 million/mm3 Rationale: The nurse should expect the client to have a decreased RBC and anemia. This finding is within the expected reference range. D) Swollen lymph nodes Rationale: The nurse should expect a client who has non-Hodgkin's lymphoma to have swollen lymph nodes.

A nurse is staging pressure ulcers on a client's foot. Which of the following areas should the nurse identify as a stage III pressure ulcer? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A) Rationale: The nurse should identify that this is a stage I pressure ulcer, which has intact skin, is reddened, does not blanch, and the tissue is firm or boggy to touch. B) Rationale: The nurse should identify that this is a stage II pressure ulcer, which does not have intact skin and has partial-thickness skin loss of the epidermis or dermis with a superficial ulcer or blister. C) Rationale: The nurse should identify that this is an unstageable pressure ulcer due to the blackened eschar in the center of the wound. D) Rationale: The nurse should identify that this is a stage III pressure ulcer, which involves full-thickness skin loss but does not extend past the underlying fascia, bones, or tendons.

A nurse is teaching a client who had an organ transplant about cyclosporine therapy. Which of the following instructions should the nurse include in the teaching? A) "Avoid drinking grapefruit juice when taking this medication." B) "Plan to discontinue taking this medication after 6 months." C) "Schedule dental examinations once per year." D) "Expect your urine to turn orange in color when taking this medication."

A) "Avoid drinking grapefruit juice when taking this medication." Rationale: The nurse should instruct the client to avoid drinking grapefruit juice while taking this medication. Grapefruit juice can decrease the metabolism of cyclosporine, which can cause an increase in serum levels and increase the risk for toxicity. B) "Plan to discontinue taking this medication after 6 months." Rationale: The nurse should instruct the client that cyclosporine is a lifelong therapy to prevent rejection of the transplanted organ. C) "Schedule dental examinations once per year." Rationale: The nurse should instruct the client to schedule dental examinations every 3 months to monitor for gingival hyperplasia. D) "Expect your urine to turn orange in color when taking this medication." Rationale: The nurse should instruct the client to report dark brown urine because this can indicate hepatotoxicity.

A nurse is providing teaching to a client who has a halo device applied to prevent further cervical spinal cord injury following a diving accident. Which of the following information should the nurse include in the teaching? A) "Avoid using a pillow when sleeping." B) "Resume driving a vehicle after 1 month." C) "Abstain from sexual activity." D) "Avoid leaning forward when attempting to stand."

A) "Avoid using a pillow when sleeping." Rationale: The nurse should instruct the client to use a pillow when sleeping for head support and to prevent pressure and pain caused by the device. B) "Resume driving a vehicle after 1 month." Rationale: The nurse should instruct the client not to drive any type of vehicle while the halo device is in place because vision is impaired when the neck is immobile. C) "Abstain from sexual activity." Rationale: The nurse should instruct the client to find a position of comfort when having intercourse. D) "Avoid leaning forward when attempting to stand." Rationale: The nurse should instruct the client that the weight of the halo device can alter balance. The client should avoid leaning forward when attempting to stand because it could cause a fall.

A nurse is teaching about preventing a vasovagal attack for a client who has a bradydysrhythmia. Which of the following information should the nurse include? A) "Bear down while having a bowel movement." B) "Use an arm reacher to grab items that are on the top shelf." C) "Apply a cold compress on your eyes to treat headaches." D) "Brush your tongue when you brush your teeth."

A) "Bear down while having a bowel movement." Rationale: The nurse should instruct the client to avoid bearing down to prevent causing a vasovagal attack. B) "Use an arm reacher to grab items that are on the top shelf." Rationale: The nurse should instruct the client to use an arm reacher to grab items that are above the client's head to prevent a vasovagal attack, which can further decrease the client's heart rate. C) "Apply a cold compress on your eyes to treat headaches." Rationale: The nurse should instruct the client to avoid using cold compresses and applying any pressure to her eyes to prevent a vasovagal attack. D) "Brush your tongue when you brush your teeth." Rationale: The nurse should instruct the client to avoid brushing her tongue, which stimulates the gag reflex, to prevent a vasovagal attack.

A nurse is teaching a newly licensed nurse about degenerative disk disease. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) "Clients who have this disease can lose a maximum of 3 inches in height." B) "I should expect to administer raloxifene daily to a client who has this disease." C) "Clients who have this disease should participate in muscle-strengthening exercises." D) "I should expect clients who have this disease to have a low bodyweight or a small frame."

A) "Clients who have this disease can lose a maximum of 3 inches in height." Rationale: Clients who have osteoporosis can lose 5 to 7.5 cm (2 to 3 inches) in height. Clients who have osteoarthritis do not lose bone density. B) "I should expect to administer raloxifene daily to a client who has this disease." Rationale: Clients who have osteoporosis receive raloxifene, an estrogen agonist, to prevent bone loss and increase bone density. C) "Clients who have this disease should participate in muscle-strengthening exercises." Rationale: The nurse should instruct the newly licensed nurse that clients who have degenerative disk disease, or osteoarthritis, should participate in muscle-strengthening exercises to increase mobility and decrease joint discomfort. D) "I should expect clients who have this disease to have a low bodyweight or a small frame." Rationale: Clients who have a low bodyweight or small frame are at risk for developing osteoporosis.

A nurse is teaching a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A) "I should wear SPF 15 sunscreen when outdoors." B) "I should inspect my skin daily for cuts and rashes." C) "I will avoid using lotion on my skin." D) "I will limit using a tanning bed to once a month."

A) "I should wear SPF 15 sunscreen when outdoors." Rationale: The client who has SLE should wear sunscreen with a sun protection factor (SPF) of 30 or higher when in sunlight. B) "I should inspect my skin daily for cuts and rashes." Rationale: The client who has SLE should inspect her skin daily for cuts and abrasions and report them to her provider. C) "I will avoid using lotion on my skin." Rationale: The client who has SLE should apply lotion to her skin to protect it from dryness. D) "I will limit using a tanning bed to once a month." Rationale: The client who has SLE should avoid using tanning beds or prolonged exposure to sunlight.

A nurse is providing teaching to a client following a kidney transplant from a cadaver donor. Which of the following statements by the client indicates an understanding of the teaching? A) "I will be on immunosuppressant therapy for 2 months." B) "I will need to continue hemodialysis until my new kidney is functioning well." C) "I should weigh myself weekly for the first 6 months." D) "I should expect my blood pressure to increase."

A) "I will be on immunosuppressant therapy for 2 months." Rationale: The client will be on immunosuppressant therapy for the lifetime of the transplanted kidney. B) "I will need to continue hemodialysis until my new kidney is functioning well." Rationale: The client will need to continue hemodialysis following kidney transplant surgery until the new kidney is functioning properly on its own. C) "I should weigh myself weekly for the first 6 months." Rationale: The client should weigh himself daily following surgery to monitor renal function. D) "I should expect my blood pressure to increase." Rationale: The client should expect blood pressure to decrease following surgery as chronic renal failure resolves.

A nurse is teaching a client who has AIDS about preventing infections. Which of the following statements by the client indicates an understanding of the teaching? A) "I will report a temperature higher than 100-degrees Fahrenheit to my doctor." B) "I should expect to have a cough." C) "I will clean my toothbrush once a month with soap." D) "I should limit eating soft-boiled eggs to once per week."

A) "I will report a temperature higher than 100-degrees Fahrenheit to my doctor." Rationale: The client who has AIDS should monitor her temperature daily and report a reading of greater than 37.8° C (100° F) to her provider. A fever can be an indication that the client has an infection. B) "I should expect to have a cough." Rationale: The client should report a cough to her provider. A cough can be an indication that the client has an infection. C) "I will clean my toothbrush once a month with soap." Rationale: The client should clean her toothbrush weekly by running it through the dishwasher or rinsing it with liquid bleach to prevent infection. D) "I should limit eating soft-boiled eggs to once per week." Rationale: The client should not eat undercooked or raw meat, fish, or eggs. Undercooked food can contain bacteria that can lead to an increased risk for infection.

A nurse is teaching a group of community members about emergency preparedness planning. Which of the following statements by a community member indicates an understanding of the teaching? A) "My children should be involved in developing our family disaster plan." B) "We should store 2 days' worth of food and water for the family." C) "We should keep a flash drive of important documents in the disaster kit." D) "I should check my disaster kit for expired items every 2 years."

A) "My children should be involved in developing our family disaster plan." Rationale: The entire family should be involved in creating the family disaster plan to ensure everyone understands the plan and knows what actions to take in the event of a disaster. B) "We should store 2 days' worth of food and water for the family." Rationale: The family should store at least 3 days' worth of food and water for the family in the event of a disaster. C) "We should keep a flash drive of important documents in the disaster kit." Rationale: The family should keep hard copies of important documents in the disaster kit, which will ensure that these documents are available in the event of a power outage. D) "I should check my disaster kit for expired items every 2 years." Rationale: The family should check the disaster kit for expired items at least every 6 months.

A nurse is providing discharge teaching for a client who has prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include? A) "Swallow the tablet whole with a glass of water." B) "Store this medication in a plastic container." C) "Take one tablet every 2 minutes if your chest pain is unrelieved." D) "Lie down when you take this medication."

A) "Swallow the tablet whole with a glass of water." Rationale: The client should place the tablet underneath her tongue and allow it to dissolve completely. B) "Store this medication in a plastic container." Rationale: The client should store the nitroglycerin in its original container, which is typically a dark-colored glass bottle or a specially made metal container that prevents inactivation of the medication caused by light or heat. Tablets that are stored in containers made of plastic or cardboard can lose their potency. C) "Take one tablet every 2 minutes if your chest pain is unrelieved." Rationale: The client should take one tablet every 5 min if her chest pain is unrelieved. The client should experience pain relief within 1 to 2 min. D) "Lie down when you take this medication." Rationale: The nurse should instruct the client to lie or sit down when taking this medication. Nitroglycerin is a vasodilator that can cause hypotension. Other adverse effects of this medication include headache, flushing, and tachycardia.

A nurse is providing discharge teaching to a client who has hepatitis. Which of the following information should the nurse include? A) "Take acetaminophen for minor aches and pains." B) "Eat low-carbohydrate, high-protein meals." C) "Avoid sexual intercourse until the antibody test is negative." D) "Wait at least 6 months before donating blood."

A) "Take acetaminophen for minor aches and pains." Rationale: The nurse should inform the client to avoid all medications, including over-the-counter medications, such as acetaminophen, unless prescribed by the provider. B) "Eat low-carbohydrate, high-protein meals." Rationale: The nurse should inform the client to eat small, frequent meals containing high-carbohydrate, moderate-fat, and moderate-protein content. C) "Avoid sexual intercourse until the antibody test is negative." Rationale: The nurse should inform the client to avoid sexual intercourse until the antibody testing results are negative. D) "Wait at least 6 months before donating blood." Rationale: The nurse should inform the client who has hepatitis that donating blood, body organs, or other body tissue is no longer a viable option.

A nurse is providing dietary teaching to a client who has chronic kidney disease and is undergoing hemodialysis. Which dietary information should the nurse include? A) "Use a salt substitute to season your food." B) "Consume a high-protein diet." C) "Include bananas in your daily diet." D) "Take an iron supplement daily"

A) "Use a salt substitute to season your food." Rationale: The nurse should instruct the client to avoid using salt substitutes, as these are often high in potassium. B) "Consume a high-protein diet." Rationale: The nurse should instruct the client to consume a low-protein diet to protect his remaining kidney function. C) "Include bananas in your daily diet." Rationale: The nurse should instruct the client to avoid bananas and other foods that are high in potassium. D) "Take an iron supplement daily" Rationale: Clients who have chronic kidney disease can experience anemia from limited protein in their diets and a decreased production of erythropoietin. The nurse should instruct the client to take a daily iron supplement to prevent anemia.

A nurse is teaching a client who has a new prescription for carvedilol following a myocardial infarction. Which of the following information should the nurse include? A) "You will experience headaches while taking this medication." B) "You should lie down before taking this medication." C) "You should take this medication on an empty stomach." D) "You should check your pulse before taking this medication."

A) "You will experience headaches while taking this medication." Rationale: The nurse should instruct a client who is taking nitrates to expect headaches while on the medication. B) "You should lie down before taking this medication." Rationale: The nurse should instruct a client who is taking nitrates to lie down before taking the medication. C) "You should take this medication on an empty stomach." Rationale: The nurse should instruct a client who is taking carvedilol to take the medication with food to minimize the risk for orthostatic hypotension. D) "You should check your pulse before taking this medication." Rationale: The nurse should instruct a client who is taking carvedilol to obtain his heart rate prior to taking the medication. The client should withhold the medication and notify his provider if his heart rate is less than 60/min.

A nurse case manager is providing discharge teaching to a client who is scheduled to receive home health visits. Which of the following statements should the nurse include in the teaching? A) "Your initial home health visit will include family and caregivers assisting with your care at home." B) "Your medical records will automatically be sent to the home health agency." C) "You will be assigned a home health doctor to follow your care." D) "You will only be able to leave your home for appointments with your doctor."

A) "Your initial home health visit will include family and caregivers assisting with your care at home." Rationale: The nurse should inform the client that the initial visit will include the client's family or caregivers who will be involved in the client's care. During this visit, the nurse will develop a treatment plan. B) "Your medical records will automatically be sent to the home health agency." Rationale: The nurse should obtain consent prior to transferring the client's medical records to the home health agency. C) "You will be assigned a home health doctor to follow your care." Rationale: The nurse should inform the client that his current provider is required to review, approve, authorize, and sign the treatment plan. This is a legal requirement for reimbursement. D) "You will only be able to leave your home for appointments with your doctor." Rationale: The nurse should inform the client who is homebound and receiving home health care that he is allowed to leave the home for occasional outings, such as a trip to get his hair cut or out for a drive.

A charge nurse is educating unit nurses about the ethical principle of nonmaleficence. Which of the following examples should the nurse include in the teaching? A) A nurse allows a client to choose the time he will ambulate. B) A nurse returns with pain medication within the time he stated to a client. C) A nurse uses a mechanical lift to move a client from a bed to a chair. D) A nurse avoids discussing a client's condition in an elevator.

A) A nurse allows a client to choose the time he will ambulate. Rationale: The nurse is using the ethical principle of autonomy by providing the client the freedom to choose the time he will ambulate. B) A nurse returns with pain medication within the time he stated to a client. Rationale: The nurse is using the ethical principle of fidelity by keeping his promise to the client to return with pain medication within the stated timeframe. C) A nurse uses a mechanical lift to move a client from a bed to a chair. Rationale: The nurse is using the ethical principle of nonmaleficence by providing a mechanical lift to move the client from the bed to the chair, which prevents harming the client. D) A nurse avoids discussing a client's condition in an elevator. Rationale: The nurse is using the ethical principle of confidentiality by avoiding discussion of client information when riding in an elevator.

A risk manager is reviewing incident reports. Which of the following incidents should the risk manager identify as a sentinel event? A) A nurse discovers an IV extravasation of a vesicant medication. B) A nurse administers an antihypertensive medication 3 hr late. C) A client leaves the facility against medical advice. D) A nurse documents client care information in the wrong medical record.

A) A nurse discovers an IV extravasation of a vesicant medication. Rationale: The risk manager should identify that the IV extravasation of a vesicant medication is a sentinel event. This can cause high local concentrations resulting in infection, pain, and loss of mobility. B) A nurse administers an antihypertensive medication 3 hr late. Rationale: A sentinel event results in significant harm to the client. A nurse administering an antihypertensive medication 3 hr late is a medication error, but it is not a sentinel event. C) A client leaves the facility against medical advice. Rationale: A sentinel event results in significant harm to the client. A client leaving the facility against medical advice places the client at risk for harm, but it is not a sentinel event. D) A nurse documents client care information in the wrong medical record. Rationale: A sentinel event results in significant harm to the client. A nurse documenting client care information in the wrong medical record is a documentation error, but it is not a sentinel event.

A nurse is planning care for a child who has cystic fibrosis. Which of the following interventions should the nurse include? A) Administer a cough suppressant to the child at bedtime. B) Discourage the child from participating in aerobic exercise. C) Give pancreatic enzymes to the child 60 min following a meal. D) Increase the child's daily fat intake to 40% of total calories.

A) Administer a cough suppressant to the child at bedtime. Rationale: The nurse should not administer a cough suppressant to a child who has cystic fibrosis. Treatment includes improving ventilation by removing mucopurulent secretions. B) Discourage the child from participating in aerobic exercise. Rationale: The nurse should encourage a child who has cystic fibrosis to participate in daily aerobic exercise to promote mucus excretion and general well-being. C) Give pancreatic enzymes to the child 60 min following a meal. Rationale: The nurse should give pancreatic enzymes to a child who has cystic fibrosis within 30 min of meals to ensure that the enzymes are mixed with food during digestion. D) Increase the child's daily fat intake to 40% of total calories. Rationale: The nurse should increase the daily fat intake to 35% to 40% of total calories for a child who has cystic fibrosis due to impaired intestinal absorption of fat.

A nurse is caring for a client who has an adrenal gland disorder. Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data. Exhibit 1: History and Physical​ Cushing's Disease: Striae on abdomen and thighs Bruising on lower extremities Open sore on ankle with cellulitis Acne on face and chest Exhibit 2: Diagnostic Results Potassium 4.6 mEq/L Sodium 149 mEq/L BUN 20 mg/dL Hemoglobin 12.8 g/dL Hematocrit 42 % Exhibit 3: Nurses' Notes Bounding peripheral pulses Distended neck veins Edema across the sacrum A) Administer an oral potassium supplement to the client. B) Apply a pressure-reducing overlay on the client's mattress. C) Check the client for orthostatic hypotension. D) Administer a 0.9% sodium chloride IV bolus to the client.

A) Administer an oral potassium supplement to the client. Rationale: The nurse should not administer an oral potassium supplement to the client, because the client's potassium level is within the expected reference range. However, the nurse should monitor the client's potassium level for hypokalemia. B) Apply a pressure-reducing overlay on the client's mattress. Rationale: The nurse should apply a pressure-reducing overlay on the client's mattress because the edema across the client's sacrum can result in a pressure ulcer. The edema is caused by hypercortisolism that leads to fluid retention. C) Check the client for orthostatic hypotension. Rationale: The nurse should check the client for hypertension because the client is experiencing manifestations of fluid volume overload, including bounding peripheral pulses, distended neck veins, and edema across the sacrum. D) Administer a 0.9% sodium chloride IV bolus to the client. Rationale: The nurse should not administer a 0.9% sodium chloride IV bolus to the client because the client's sodium level is above the expected reference range, which can lead to fluid volume overload. A client who has adrenal gland hyperfunction or Cushing's disease can have hypernatremia and fluid retention.

A nurse is planning care for a client who has viral encephalitis and is starting to take IV acyclovir. Which of the following interventions should the nurse include in the plan? A) Administer the medication via infusion pump over 30 min. B) Monitor kidney function studies after infusing the medication. C) Use the reconstituted solution within 36 hr. D) Restrict the client's IV fluids after infusing the medication.

A) Administer the medication via infusion pump over 30 min. Rationale: The nurse should administer acyclovir to the client over 1 hr via infusion pump because acyclovir can precipitate in the renal tubules and cause kidney damage. B) Monitor kidney function studies after infusing the medication. Rationale: The nurse should monitor the client's kidney function because acyclovir can precipitate in the renal tubules and cause kidney damage. C) Use the reconstituted solution within 36 hr. Rationale: The nurse should use the reconstituted solution within 24 hr to maintain the stability of the medication. D) Restrict the client's IV fluids after infusing the medication. Rationale: The nurse should increase client's IV fluids by 2,000 to 3,000 L, especially for the first 2 hr after the medication is infused, because acyclovir can precipitate in the renal tubules and cause kidney damage.

A nurse is preparing to administer platelets to a client who has thrombocytopenia. Which of the following actions should the nurse plan to take? A) Administer the platelets to the client over 4 hr. B) Warm the platelets for 30 min prior to infusion. C) Ensure that the client's blood type matches the platelets. D) Transfuse the platelets through a small filter.

A) Administer the platelets to the client over 4 hr. Rationale: The nurse should administer the platelets to the client over 15 to 30 min to prevent platelet clumping. B) Warm the platelets for 30 min prior to infusion. Rationale: The nurse should administer the platelets to the client immediately without warming to prevent platelet clumping. C) Ensure that the client's blood type matches the platelets. Rationale: The nurse does not need to match the client's blood type to the platelets because the platelets are pulled from multiple donors and have no antigens. D) Transfuse the platelets through a small filter. Rationale: The nurse should transfuse the platelets through a small filter to remove white blood cells.

A nurse manager is teaching a group of nurses about professional negligence. Which of the following situations should the nurse manager include as an example? A) Administering digoxin 0.25 mg oral for a client's morning dose B) Administering heparin to a client who is undergoing a lumbar puncture C) Withholding metformin from a client who has diabetic ketoacidosis D) Administering potassium IV bolus at a rate of 10 mEq/hr

A) Administering digoxin 0.25 mg oral for a client's morning dose Rationale: Digoxin 0.25 mg is within the expected dosage range. Therefore, this is not an example of negligence. B) Administering heparin to a client who is undergoing a lumbar puncture Rationale: A nurse who administers heparin to a client who is undergoing a lumbar puncture is an example of negligence. Anticoagulant medication can cause bleeding in the lumbar area. C) Withholding metformin from a client who has diabetic ketoacidosis Rationale: A nurse should withhold metformin and any type of antidiabetic medication from a client who has diabetic ketoacidosis. Therefore, this is not an example of negligence. D) Administering potassium IV bolus at a rate of 10 mEq/hr Rationale: A nurse should administer potassium IV bolus at a rate of no greater than 10 mEq/hr. Therefore, this is not an example of negligence.

A nurse manager is discussing Medicare reimbursement with a group of staff nurses. The nurse should identify that Medicare will deny reimbursement for which of the following events? A) Allergic reaction to an immunization B) Additional round of antibiotics for the treatment of community-acquired pneumonia C) Fractured hip from a fall while ambulating postoperatively D) Adverse effect of constipation from morphine

A) Allergic reaction to an immunization Rationale: Allergic reactions are a potential response to immunizations. Treatment of allergic reactions is reimbursed by Medicare. B) Additional round of antibiotics for the treatment of community-acquired pneumonia Rationale: Clients who have uncomplicated pneumonia can receive treatment for 5 to 7 days. However, clients who are immunocompromised can require treatment for up to 21 days. Treatment of community-acquired pneumonia is reimbursed by Medicare. C) Fractured hip from a fall while ambulating postoperatively Rationale: Medicare denies reimbursement for "never events." These events are considered preventable and include hospital-acquired infections, injuries resulting from a client fall, and surgery performed to an incorrect site. D) Adverse effect of constipation from morphine Rationale: Constipation is a common adverse effect of morphine. Treatment of adverse effects is reimbursed by Medicare.

A nurse monitoring a client who had a stroke. The nurse should identify which of the following findings as an indication of increased intracranial pressure? A) Decreased body temperature B) Hypertension C) Tachycardia D) Narrowed pulse pressure

A) Decreased body temperature Rationale: The nurse should monitor for an increased body temperature, because a fever can extend the area of damage in the brain following a stroke. B) Hypertension Rationale: The nurse should identify hypertension as an indication of increased intracranial pressure. Other indications include a widened pulse pressure and bradycardia. C) Tachycardia Rationale: The nurse should monitor for bradycardia as an indication of increased intracranial pressure. D) Narrowed pulse pressure Rationale: The nurse should monitor for widened pulse pressure as an indication of increased intracranial pressure.

A nurse in the emergency department is caring for four clients. Which of the following clients should the nurse identify as requiring mandatory reporting? A) An adult client who is being treated for a deep-vein thrombosis. B) An adult client who admits to using methamphetamines. C) A child who is accompanied by a parent to be treated for patterned burns on the arms. D) An older adult client who is being treated at home for a stage 2 pressure ulcer.

A) An adult client who is being treated for a deep-vein thrombosis. Rationale: The nurse should identify that an adult client who is being treated for a deep-vein thrombosis does not require mandatory reporting. B) An adult client who admits to using methamphetamines. Rationale: The nurse should identify that an adult client who admits to using methamphetamines does not require mandatory reporting. C) A child who is accompanied by a parent to be treated for patterned burns on the arms. Rationale: The nurse should identify that a child who is accompanied by a parent to be treated for patterned burns on the arms requires mandatory reporting for suspected physical abuse. D) An older adult client who is being treated at home for a stage 2 pressure ulcer. Rationale: The nurse should identify that an older adult client who is being treated at home for a stage 2 pressure ulcer does not require mandatory reporting.

A nurse is preparing to administer nitroglycerin topical ointment to a client who has a myocardial infarction. Which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all steps.) A) Apply a thin layer of medication ointment to the dosing paper. B) Spread the medication over a 6.4 by 8.9 cm (2.5 by 3.5 in) area of skin. C) Cleanse the client's skin and allow it to dry. D) Remove the medication in 6 hr. E) Cover the medication site with plastic wrap.

A) Apply a thin layer of medication ointment to the dosing paper. B) Spread the medication over a 6.4 by 8.9 cm (2.5 by 3.5 in) area of skin. C) Cleanse the client's skin and allow it to dry. D) Remove the medication in 6 hr. E) Cover the medication site with plastic wrap. Answer: C, A, B, E, D Rationale: The nurse should first cleanse the client's skin with soap and water and allow it to dry. The selected skin site should also be hairless. This allows the medication to absorb better into the client's peripheral veins. Second, the nurse should apply a thin layer of the medication to the proper dosing paper supplied by the medication's pharmaceutical company. This ensures the nurse is measuring the correct amount of ointment for the medication tube, which should be 2.5 to 5.1 cm (1 to 2 in) depending on the prescribed dose by the provider. Third, the nurse should spread the medication over an area of 6.4 by 8.9 cm (2.5 by 3.5 in) onto the client's skin. The thickness of the medication allows it to absorb into the client's bloodstream, which dilates the peripheral veins. Fourth, the nurse should cover the medication ointment site on the client's skin with plastic wrap. This allows the medication to remain contained so that it can absorb effectively into the client's skin. Fifth, the nurse should remove the medication every 4 to 6 hr from the client's skin. The medication is fully absorbed after this time period and a new site should be selected to apply another dose.

A nurse is caring for a client who is 6 hr. postoperative following a total knee replacement. Which of the following actions should the nurse take to prevent a pulmonary embolism? A) Apply compression stockings to both of the client's legs. B) Place a pillow under the client's unaffected knee. C) Massage both of the client's lower legs every 4 hr. D) Instruct the client to hold his breath while turning in bed.

A) Apply compression stockings to both of the client's legs. Rationale: The nurse should apply compression stockings to both of the client's legs to prevent the formation of a pulmonary embolism. B) Place a pillow under the client's unaffected knee. Rationale: The nurse should avoid placing a pillow under either of the client's knees, as this can constrict blood flow, which can result in a pulmonary embolism. C) Massage both of the client's lower legs every 4 hr. Rationale: The nurse should avoid massaging either of the client's legs, as this can dislodge a clot that has already developed, which can result in a pulmonary embolism. D) Instruct the client to hold his breath while turning in bed. Rationale: The nurse should instruct the client to avoid holding his breath during turning because this will result in a Valsalva maneuver, which can dislodge a clot that has already developed and result in a pulmonary embolism.

A nurse is caring for a client who has a new diagnosis of esophageal cancer. The client's family tells the nurse that they do not want the client to know the diagnosis. Which of the following actions should the nurse take to uphold client autonomy? A) Ask the provider to respect the family's decision to withhold the diagnosis. B) Tell the family the client has the right to know about her health. C) Agree to keep the diagnosis information from the client. D) Request pastoral care to inform the client of her condition.

A) Ask the provider to respect the family's decision to withhold the diagnosis. Rationale: The nurse is demonstrating paternalism by asking the provider to respect the family's decision to withhold the diagnosis. B) Tell the family the client has the right to know about her health. Rationale: The nurse is demonstrating the ethical principle of autonomy by respecting the client's right to make decisions about her health. C) Agree to keep the diagnosis information from the client. Rationale: The nurse is demonstrating paternalism by agreeing to keep the diagnosis information from the client. D) Request pastoral care to inform the client of her condition. Rationale: The nurse is breaching confidentiality by requesting pastoral care to inform the client of her condition.

A nurse is teaching an educational session about reducing health care-associated infections. Which of the following instructions should the nurse include? A) Bathe clients daily with chlorhexidine wipes. B) Shave a client's skin prior to surgical procedures. C) Wash hands for 10 seconds between caring for clients. D) Loop urinary drainage tubing on a client's bed.

A) Bathe clients daily with chlorhexidine wipes. Rationale: According to research-based care, the nurse should bathe clients daily with chlorhexidine wipes to reduce the risk for health care-associated infections. B) Shave a client's skin prior to surgical procedures. Rationale: According to research-based care, the nurse should clip the client's hair prior to surgical procedures. Shaving can cause abrasions, which can be portals for bacterial infections. C) Wash hands for 10 seconds between caring for clients. Rationale: According to research-based care, the nurse should wash her hands for 15 to 20 seconds between client care to reduce the risk for health care-associated infections. D) Loop urinary drainage tubing on a client's bed. Rationale: According to research-based care, the nurse should avoid a dependent loop in the urinary drainage tubing, as this can be a source of bacterial growth.

A nurse is performing an admission assessment on a client who has meningitis. Which of the following findings should the nurse expect? A) Positive Chvostek's sign B) Positive Cullen sign C) Positive Trousseau's sign D) Positive Kernig's sign

A) Positive Chvostek's sign Rationale: A positive Chvostek's sign is an expected finding of hypocalcemia. B) Positive Cullen sign Rationale: A positive Cullen sign is an expected finding of acute pancreatitis. C) Positive Trousseau's sign Rationale: A positive Trousseau's sign is an expected finding of hypocalcemia. D) Positive Kernig's sign Rationale: A positive Kernig's sign is an expected finding of meningitis due to meningeal irritation. When Kernig's sign is present, the client cannot fully extend her leg when lying supine with her thigh flexed toward her abdomen.

A nurse is assessing a client who has a do-not-resuscitate (DNR) order and has stopped breathing. The family asks the nurse to resuscitate the client. Which of the following actions should the nurse take? A) Begin CPR on the client. B) Respect the client's preferences. C) Apply oxygen at 4 L/min via nasal cannula. D) Gather equipment for mechanical ventilation.

A) Begin CPR on the client. Rationale: The nurse should not begin CPR on the client, because this action goes against the client's DNR order. B) Respect the client's preferences. Rationale: The nurse should inform the client's family that he is obligated to respect the client's preferences and follow the DNR order. C) Apply oxygen at 4 L/min via nasal cannula. Rationale: The nurse should not apply oxygen at 4 L/min via nasal cannula, because this action goes against the client's DNR order. D) Gather equipment for mechanical ventilation. Rationale: The nurse should not gather equipment for mechanical ventilation, because this action goes against the client's DNR order.

A nurse is caring for a client who is in the active phase of labor and has an amniotic fluid embolis. Which of the following actions should the nurse take? A) Begin a heparin infusion for the client. B) Initiate seizure precautions for the client. C) Administer terbutaline to the client. D) Give oxygen via nonrebreather mask at 10 L/min.

A) Begin a heparin infusion for the client. Rationale: Coagulation failure is a manifestation of amniotic fluid embolis. Therefore, the nurse should not begin a heparin infusion. B) Initiate seizure precautions for the client. Rationale: The nurse should initiate seizure precautions for a client who has preeclampsia. C) Administer terbutaline to the client. Rationale: Terbutaline is a tocolytic medication that relaxes the uterine smooth muscle and is used to suppress preterm labor. Therefore, the nurse should not administer terbutaline. D) Give oxygen via nonrebreather mask at 10 L/min. Rationale: The nurse should administer oxygen via nonrebreather mask at 10 L/min and prepare for intubation and mechanical ventilation.

A chief nursing officer (CNO) is comparing the quality of health care facility to the best-performing facilities nationwide to determine if quality improvement is required. Which of the following processes should the CNO plan to use as a comparison tool? A) Benchmarking B) Standard of excellence C) Quality gap D) Resource utilization

A) Benchmarking Rationale: Benchmarking measures products, services, and practice against top-performing organizations. Facilities use this as a tool for developing desired standards of organizational performance. B) Standard of excellence Rationale: Standard of excellence is a predetermined level used by facilities as a guide for practice. These standards are tools of measurement. Therefore, they should be objective, achievable, and measurable. C) Quality gap Rationale: Quality gap is the difference in performance between the top health care facilities and the national average. However, this process does not compare her facility to the best-performing facilities. D) Resource utilization Rationale: The nurse uses resource utilization to plan and provide nursing resources within health care facilities that are financially responsible, safe, and effective.

A nurse caring for a client who has sepsis. Which of the following manifestations should indicate to the nurse that the client might be progressing to septic shock? A) Bradycardia B) Hypertension C) Hypothermia D) Polyuria

A) Bradycardia Rationale: The nurse should recognize that a client who is progressing to septic shock can experience tachycardia as a result of the body's attempt to preserve organ function. B) Hypertension Rationale: The nurse should recognize that a client who is progressing to septic shock can experience hypotension as a result of the body's inability to compensate for the infection. C) Hypothermia Rationale: The nurse should recognize that a client who is progressing to septic shock can experience hypothermia as a result of the body's inability to compensate for the infection. D) Polyuria Rationale: The nurse should recognize that a client who is progressing to septic shock can experience decreased urine production as organ failure occurs.

A nurse suspects that a client is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A) Check the client for sacral edema. B) Raise the head of the client's bed. C) Obtain the client's blood pressure in both arms. D) Prepare the client for a chest x-ray.

A) Check the client for sacral edema. Rationale: The nurse should check the client for sacral edema to assess for fluid retention or bleeding in the body. However, there is another action the nurse should take first. B) Raise the head of the client's bed. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to raise the head of the bed to allow for ease of breathing and better oxygenation. C) Obtain the client's blood pressure in both arms. Rationale: The nurse should obtain the client's blood pressure in both arms to assess his cardiac status and adequacy of perfusion. However, there is another action the nurse should take first. D) Prepare the client for a chest x-ray. Rationale: The nurse should prepare the client for a chest x-ray to diagnose the presence of a pulmonary embolism in his lung. However, there is another action the nurse should take first.

A nurse is caring for a client who has a partial-thickness burn and a prescription for silver sulfadiazine cream. Which of the following interventions should the nurse take? A) Check the client's D-dimer levels every 12 hr. B) Apply the medication cream to the client's wound every 4 hr. C) Monitor the client's white blood cell count. D) Clean the client's wound with povidone-iodine before application.

A) Check the client's D-dimer levels every 12 hr. Rationale: The nurse should monitor the client's kidney function studies and liver enzymes because silver sulfadiazine cream can cause systemic adverse reactions that can lead to kidney or liver damage. B) Apply the medication cream to the client's wound every 4 hr. Rationale: The nurse should apply the medication to the client's wound once or twice daily. C) Monitor the client's white blood cell count. Rationale: The nurse should monitor the client's white blood cell count because a drop in the white blood cell count can be an indication of an allergic reaction to the silver sulfadiazine cream. D) Clean the client's wound with povidone-iodine before application. Rationale: The nurse should clean the client's wound with mild soap and water before applying the silver sulfadiazine cream.

A nurse is caring for a client who has a pressure ulcer. Which of the following actions should the nurse take when cleaning the client's wound? A) Clean the client's wound with sterile water. B) Pat the client's wound dry after cleaning. C) Use a cotton swab to clean the center of the client's wound. D) Warm the cleaning solution to the client's body temperature.

A) Clean the client's wound with sterile water. Rationale: According to practice guidelines, the nurse should clean the wound with an isotonic saline solution, rather than sterile water, to promote healing. B) Pat the client's wound dry after cleaning. Rationale: According to practice guidelines, the nurse should avoid drying the wound after cleaning to promote healing. C) Use a cotton swab to clean the center of the client's wound. Rationale: According to practice guidelines, the nurse should use gauze squares instead of cotton swabs to clean the wound to prevent fibers from entering the wound. D) Warm the cleaning solution to the client's body temperature. Rationale: According to practice guidelines, the nurse should warm the cleaning solution to body temperature. This action prevents the solution from lowering the wound temperature and promotes healing.

A nurse manager suspects that a nurse is chemically impaired. Which of the following actions should the nurse manager take first? A) Collect data about the nurse's behavior, work performance, and attendance. B) Remove the nurse from the work environment. C) Confront the nurse about suspected substance use. D) Schedule a meeting with the nurse to discuss the incident.

A) Collect data about the nurse's behavior, work performance, and attendance. Rationale: The nurse manager should collect data about the nurse's behavior, work performance, and attendance in order to substantiate the suspicion of substance use. However, there is another action the nurse manager should take first. B) Remove the nurse from the work environment. Rationale: The greatest risk in this situation is a potentially chemically impaired nurse causing injury to clients. Therefore, the first action the nurse manager should take is to remove the nurse from the work environment. C) Confront the nurse about suspected substance use. Rationale: The nurse manager should confront the nurse to address the suspected substance use. However, there is another action the nurse manager should take first. D) Schedule a meeting with the nurse to discuss the incident. Rationale: The nurse manager should schedule a meeting with the nurse to occur within 24 hr to discuss the incident. However, there is another action the nurse manager should take first.

A nurse is providing preoperative teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? A) Contact a trained interpreter to translate the teaching for the client. B) Translate the teaching for the client using a bilingual dictionary. C) Ask the client's family member to translate the teaching for the client. D) Use a computer-generated translation service to translate the teaching for the client.

A) Contact a trained interpreter to translate the teaching for the client. Rationale: The nurse's role is to contact a professional interpreter who is trained in medical terminology to promote the client's understanding of the teaching. B) Translate the teaching for the client using a bilingual dictionary. Rationale: The nurse should not translate the teaching, as this can result in translation errors and impede the client's understanding of the teaching. C) Ask the client's family member to translate the teaching for the client. Rationale: The nurse should not ask the client's family member to translate the teaching, as this can result in translation errors and violate the client's privacy. D) Use a computer-generated translation service to translate the teaching for the client. Rationale: The nurse should not translate the teaching, even using a computer-generated translation service, as this can result in translation errors and impede client's understanding of the teaching.

A nurse is teaching a group of nurses about the role of a case manager. Which of the following information should the nurse include in the teaching? A) Coordinates the ethics committee B) Identifies cost-effective equipment C) Directs care limited to outpatient settings D) Provides direct care to clients

A) Coordinates the ethics committee Rationale: The nurse should inform the group that the case manager oversees services and resources for multiple clients in a timely manner and does not coordinate an ethics committee. B) Identifies cost-effective equipment Rationale: The nurse should inform the group that the case manager identifies treatments, care settings, and equipment to promote cost-effective positive outcomes. C) Directs care limited to outpatient settings Rationale: The nurse should inform the group that the case manager oversees services and resources for multiple clients in both inpatient and outpatient settings. D) Provides direct care to clients Rationale: The nurse should inform the group that the case manager oversees services and resources for multiple clients and does not provide direct care to clients.

A nurse is preparing to provide wound care on a client who has a stage I pressure ulcer. Which of the following characteristics should the nurse expect the ulcerative skin are to have? A) Damage to the underlying muscle B) Partial-thickness skin loss C) Necrosis of subcutaneous tissue D) Nonblanchable and reddened

A) Damage to the underlying muscle Rationale: The nurse should expect a stage IV pressure ulcer to appear as an area on the client's skin with damage that has extended to the underlying muscle, bone, or other supporting structures. B) Partial-thickness skin loss Rationale: The nurse should expect a stage II pressure ulcer to appear as an area on the skin with partial-thickness skin loss. C) Necrosis of subcutaneous tissue Rationale: The nurse should expect the client who has a stage III pressure ulcer to have an area of full-thickness skin loss. The ulcer can damage and necrose through the subcutaneous tissue. D) Nonblanchable and reddened Rationale: The nurse should expect a nonblanchable reddened area on the skin on a client for a stage I pressure ulcer.

A nurse is caring for a client who has hepatic encephalopathy and is receiving lactulose. The nurse should identify that which of the following findings indicates a therapeutic effect of the medication? A) Decreased abdominal girth B) Decreased ammonia level C) Decreased heart rate D) Decreased abdominal cramping

A) Decreased abdominal girth Rationale: The nurse should monitor the client for a decreased abdominal girth as an indication of the effectiveness of diuretic therapy. B) Decreased ammonia level Rationale: The nurse should identify that a decrease in the client's ammonia level is a therapeutic effect of lactulose. This medication decreases ammonia levels by producing a laxative effect. Another therapeutic effect of the medication is decreased confusion. C) Decreased heart rate Rationale: The nurse should identify that a decreased heart rate is a therapeutic effect of beta blockers. These medications can be given to reduce hepatic venous pressure and bleeding. D) Decreased abdominal cramping Rationale: The nurse should identify abdominal cramping as an adverse effect of lactulose.

A nurse is caring for a client who has Addison's disease and is receiving an infusion of 0.9% sodium chloride. Which of the following actions should the nurse take? A) Discontinue the client's IV infusion. B) Offer high-potassium foods for the client. C) Administer spironolactone to the client. D) Check the client's blood glucose level.

A) Discontinue the client's IV infusion. Rationale: The nurse should maintain the IV infusion of 0.9% sodium chloride to prevent hyponatremia. B) Offer high-potassium foods for the client. Rationale: The nurse should implement a decreased-potassium diet for a client who has hyperkalemia, which is a manifestation of acute adrenal insufficiency. C) Administer spironolactone to the client. Rationale: The nurse should avoid administering potassium-sparing diuretics to a client who has hyperkalemia, which is a manifestation of acute adrenal insufficiency. D) Check the client's blood glucose level. Rationale: The nurse should check the client's blood glucose level because hypoglycemia is a manifestation of acute adrenal insufficiency. The nurse should monitor the client's blood glucose level hourly.

A nurse is caring for a client who is 24 hr. postoperative following lumbar spinal surgery to treat degenerative disk disease. Which of the following findings should the nurse report to the provider as a possible complication of the surgery? A) Drain output of 200 mL in 8 hr B) Client requires assistance to turn in bed C) Temperature 37.3° C (99.2° F) D) Clear drainage on dressings

A) Drain output of 200 mL in 8 hr Rationale: Drain output of 200 mL in 8 hr A drain output of 200 mL in 8 hr is an expected finding. The nurse should immediately report a drain output of 250 mL or greater in 8 hr to the provider. B) Client requires assistance to turn in bed Rationale: The client requiring assistance to turn in bed is an expected finding. The nurse can use a turning sheet to help the client logroll. C) Temperature 37.3° C (99.2° F) Rationale: A low-grade temperature, such as 37.3° C (99.2° F), is an expected finding in the first 24 hr following surgery. A spike in the temperature in the second day following the surgery could indicate infection and should be immediately reported to the provider. D) Clear drainage on dressings Rationale: The nurse should identify that clear drainage on or around the client's dressings can indicate a cerebral spinal fluid leak. The nurse should place the client flat and immediately report this finding to the provider.

A nurse manager is teaching a newly licensed nurse about the Emergency Medical Treatment and Active Labor Act (EMTALA). Which of the following information should the nurse incluede? A) EMTALA requires that clients receive written information about health care advance directives. B) EMTALA protects the privacy of clients' health care information. C) EMTALA protects health care personnel from liability if they offer medical assistance outside the workplace. D) EMTALA requires that all clients are stable prior to discharge or transfer.

A) EMTALA requires that clients receive written information about health care advance directives. Rationale: The Patient Self-Determination Act requires that clients receive written information about health care advance directives. B) EMTALA protects the privacy of clients' health care information. Rationale: The Health Insurance Portability and Accountability Act protects the privacy of clients' health care information. C) EMTALA protects health care personnel from liability if they offer medical assistance outside the workplace. Rationale: Good Samaritan laws protect health care personnel from liability if they offer medical assistance outside the workplace. D) EMTALA requires that all clients are stable prior to discharge or transfer. Rationale: EMTALA requires that clients are stable before they can be discharged or transferred. This act also prohibits refusing to care for clients who are indigent or uninsured.

A nurse is caring for a client who is postoperative following a craniotomy to remove a brain tumor. The nurse should notify the provider about which of the following findings? A) Edema and bruising around the eyes B) Incisional drainage of 50 mL in 8 hr C) Intracranial pressure of 13 mm Hg D) Fixed and nonreactive pupils to light

A) Edema and bruising around the eyes Rationale: The nurse should identify that edema and bruising around the eyes, also known as periorbital edema, is an expected finding following a craniotomy. B) Incisional drainage of 50 mL in 8 hr Rationale: The nurse should identify that incisional drainage of 30 to 50 mL in 8 hr following a craniotomy is an expected finding. The nurse should measure and record the drainage amount every 8 hr. C) Intracranial pressure of 13 mm Hg Rationale: The nurse should identify that an intracranial pressure of 13 mm Hg is within the expected reference range. D) Fixed and nonreactive pupils to light Rationale: The nurse should notify the provider if the client's pupils are fixed and non-reactive to light. This is an indication of a neurological deficit due to a herniation of the brain.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take first? A) Elevate the client's legs. B) Administer a vasopressor medication to the client. C) Obtain the client's ABG levels. D) Measure the client's temperature.

A) Elevate the client's legs. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to elevate the client's legs to promote venous return of blood to the heart. This action makes it easier for the client to breathe and increases blood pressure and cardiac output. B) Administer a vasopressor medication to the client. Rationale: The nurse should administer a vasopressor medication to the client to vasoconstrict the client's blood vessels, which increases the client's blood pressure. However, there is another action the nurse should take first. C) Obtain the client's ABG levels. Rationale: The nurse should obtain the client's ABG levels to monitor her pH level. However, there is another action the nurse should take first. D) Measure the client's temperature. Rationale: The nurse should measure the client's temperature to monitor for hypothermia as a possible result of receiving IV replacement fluids too rapidly. However, there is another action the nurse should take first.

A nurse is reviewing the diagnostic test results of a client who is suspected of having Cushing's disease. The nurse should identify that which of the following findings supports this diagnosis? A) Elevated lymphocyte count B0 Decreased urine glucose level C) Elevated salivary cortisol level D) Decreased sodium level

A) Elevated lymphocyte count Rationale: The nurse should expect a client who has Cushing's disease to have a decreased lymphocyte count. B) Decreased urine glucose level Rationale: The nurse should expect a client who has Cushing's disease to have an increased urine glucose level. C) Elevated salivary cortisol level Rationale: The nurse should expect a client who has Cushing's disease, also known as hypercortisolism, to have an elevated salivary cortisol level. D) Decreased sodium level Rationale: The nurse should expect a client who has Cushing's disease to have an increased sodium level.

A nurse is reviewing the laboratory results of a client who has severe burns from a home fire that occured 6 hr. ago. Which of the following findings should the nurse expect? A) Elevated sodium level B) Decreased hemoglobin level C) Decreased hematocrit level D) Elevated potassium level

A) Elevated sodium level Rationale: The nurse should anticipate a client who had a severe burn within the last 12 hr to have decreased sodium levels. Sodium is retained in the body as a result of the endocrine system's response to the body's stress. B) Decreased hemoglobin level Rationale: The nurse should anticipate a client who had a severe burn within the last 12 hr to have increased hemoglobin and hematocrit levels as blood osmolarity increases from vascular dehydration. C) Decreased hematocrit level Rationale: The nurse should anticipate a client who had a severe burn within the last 12 hr to have increased hemoglobin and hematocrit levels as blood osmolarity increases from vascular dehydration. D) Elevated potassium level Rationale: The nurse should anticipate a client who had a severe burn within the last 12 hr to have fluid shifts that result in an elevated potassium level, which occurs as a result of cellular injury due to hypovolemia.

A nurse in risk management is evaluation a sentinel event. Which of the following actions should the nurse take? A) Facilitate a change in the facility client assignments. B) Gather data to compare negligence with other facilities. C) Develop a plan to reduce the risk for client injury. D) Implement new facility policies.

A) Facilitate a change in the facility client assignments. Rationale: The nurse can facilitate changes within the facility to prevent future errors, but the nurse cannot change client assignments. B) Gather data to compare negligence with other facilities. Rationale: The nurse can gather data within the facility, rather than other facilities, to reduce the risk for negligence and prevent another sentinel event from occurring. C) Develop a plan to reduce the risk for client injury. Rationale: The nurse should develop a plan to reduce the risk for negligence and prevent another sentinel event from occurring. D) Implement new facility policies. Rationale: The nurse can assist in developing policies but does not implement new facility policies.

A nurse manager is informed that the family of a client is preparing to file a malpractice lawsuit. The nurse should identify which of the following situations as a potential malpractice? A) Failure to meet the family's expectations of care B) Adverse reaction to a prescribed medication C) Failure to identify an infiltrated IV D) Adverse outcome following a surgical procedure

A) Failure to meet the family's expectations of care Rationale: The nurse manager should identify that failure to meet the family's expectations of care is not considered malpractice. Nurses are obligated to follow professional standards of care for all clients. B) Adverse reaction to a prescribed medication Rationale: The nurse manager should identify that an adverse reaction to a prescribed medication is not considered malpractice. This type of harm to the client is unforeseen, and malpractice requires the foreseeability of harm. C) Failure to identify an infiltrated IV Rationale: The nurse manager should identify that failure to provide reasonable care, such as identifying IV infiltration, can contribute to malpractice. The nurse should provide care that a reasonably prudent nurse would provide under the same circumstances. D) Adverse outcome following a surgical procedure Rationale: The nurse manager should identify that an adverse outcome following a surgical procedure is not considered malpractice. This type of harm to the client is unforeseen, and malpractice requires the foreseeability of harm.

A nurse manager is teaching about the failure to communicate during a staff educational session. Which of the following examples should the nurse manager include? A) Failure to report elevated blood pressure during change of shift report B) Failure to complete the musculoskeletal portion of an examination C) Failure to question an illegible prescription D) Failure to identify shortness of breath as a manifestation of pulmonary embolism

A) Failure to report elevated blood pressure during change of shift report Rationale: Failure to communicate involves failing to report accurate information in a timely manner. A nurse failing to report elevated blood pressure during change of shift report could result in adverse client outcomes. B) Failure to complete the musculoskeletal portion of an examination Rationale: A nurse failing to complete the musculoskeletal portion of an examination is an example of failure to assess and monitor. C) Failure to question an illegible prescription Rationale: A nurse failing to question an illegible prescription is an example of failure to act as a client advocate. D) Failure to identify shortness of breath as a manifestation of pulmonary embolism Rationale: A nurse failing to identify shortness of breath as a manifestation of pulmonary embolism is an example of failure to assess and monitor.

A charge nurse is facilitating conflict resolution between two coworkers regarding a client assignment. Which of the following conflict management strategies should the charge nurse use first? A) Focus on the issue to resolve and meet the needs of each coworker. B) Determine how each coworker manages personal conflicts. C) Ask both of the coworkers for information about the situation. D) Listen attentively to the concerns of each coworker.

A) Focus on the issue to resolve and meet the needs of each coworker. Rationale: The nurse should focus on the issues in order to find a resolution to meet the needs of each coworker. However, evidence-based practice indicates that the nurse should perform another action first. B) Determine how each coworker manages personal conflicts. Rationale: Evidence-based practice indicates the charge nurse first needs to understand the conflict management style of each coworker. Respecting each other's feelings about the conflict and realizing that everyone handles conflicts differently are the first steps to successfully resolving the conflict. C) Ask both of the coworkers for information about the situation. Rationale: The nurse should ask both nurses about the situation to help resolve the conflict. However, evidence-based practice indicates that the nurse should perform another action first. D) Listen attentively to the concerns of each coworker. Rationale: The nurse should listen to the concerns of each coworker to understand both sides of the situation. However, evidence-based practice indicates that the nurse should perform another action first.

A nurse is preparing to conduct research regarding catheter-related infections for a performance improvement initiative. Which of the following activities should the nurse identify as components of the research process? (Select all that apply.) A) Formulate the research problem. B) Review literature from any available web-based resources. C) Obtain approval from the American Nurses Association (ANA). D) Conduct a pilot study. E) Communicate the conclusions of the study.

A) Formulate the research problem. Rationale: This action allows the nurse to define the purpose of the study and determine the type of research design she will use. B) Review literature from any available web-based resources. Rationale: The nurse should review reliable sources concerning the research problem, including systematic reviews, pre-appraised literature, and studies from peer-reviewed journals. The nurse should evaluate the quality of web-based materials on the internet prior to including the information in the research. C) Obtain approval from the American Nurses Association (ANA). Rationale: The nurse does not need to obtain approval from the ANA to conduct the research. The nurse can contact the ANA for research funds, as the ANA can award small research grants through the American Nurses Foundation. D) Conduct a pilot study. Rationale: The nurse should conduct a pilot study, which can assist the nurse to identify the strengths and limitations of a planned larger-scale study. It can also assist with the assessment of the design and methodology of the research. E) Communicate the conclusions of the study. Rationale: The nurse should communicate the conclusions of the pilot study and the research conducted. Once the outcomes are disseminated, the new evidence-based practice can be incorporated into the daily practice of the facility.

A nurse caring for a client identifies an ethical dilemma concerning the client's treatment. Which of the following actions should the nurse take next? A) Gather relevant information B) Reflect on his own values C) Verbalize the problem D) Determine possible courses of action

A) Gather relevant information Rationale: Using an ethical decision-making model, after the nurse identifies an ethical dilemma, he should gather relevant information including who is involved with the problem and information about the client's health. B) Reflect on his own values Rationale: The nurse should reflect on his own values as part of the ethical decision-making model; however there is another action the nurse should take first. C) Verbalize the problem Rationale: The nurse should verbalize the problem as part of the ethical decision-making model; however there is another action the nurse should take first. D) Determine possible courses of action Rationale: The nurse should determine possible courses of action as part of the ethical decision-making model; however there is another action the nurse should take first.

Following a mass casualty disaster, a nurse is assigning a triage tag to a responsive client who has a major burn injury covering 15% of his body surface area. Which of the following triage categories should the nurse assign to the client? A) Green B) Yellow C) Red D) Black

A) Green Rationale: The nurse should assign a green tag to a client who has a minor injury that does not require immediate treatment. B) Yellow Rationale: The nurse should assign a yellow tag to a client who has a significant injury that does not require immediate treatment. C) Red Rationale: The nurse should assign a red tag to a client who has a significant injury that requires immediate treatment, such as the client who has a major burn injury covering 15% of his body surface area. D) Black Rationale: The nurse should assign a black tag to a client who has extensive injuries and a minimal chance of survival.

A nurse is caring for a client who has cirrhosis. The client has an ammonia level of 120 mcg/dL, slurred speech, and is disoriented to person and place. The nurse should identify that these findings possible indicate which of the following complications of cirrhosis? A) Hepatorenal syndrome B) Portal hypertension C) Gastroesophageal varices D) Hepatic encephalopathy

A) Hepatorenal syndrome Rationale: The nurse should suspect hepatorenal syndrome if the client develops sudden oliguria and has elevated BUN and creatinine levels. B) Portal hypertension Rationale: The nurse should suspect portal hypertension if the client develops splenomegaly and ascites. C) Gastroesophageal varices Rationale: The nurse should suspect gastroesophageal varices if the client develops hematemesis and melena. D) Hepatic encephalopathy Rationale: The nurse should recognize that an elevated ammonia level, slurred speech, and mental status changes are early manifestations of hepatic encephalopathy, which is a possible complication of cirrhosis. An ammonia level of 120 mcg/dL is above the expected reference range.

A nurse is assessing an infant who has meningitis. Which of the following manifestations should the nurse expect? A) Hypertonicity B) Hypothermia C) Sunken fontanel D) Lethargy

A) Hypertonicity Rationale: The nurse should expect the infant to have hypotonicity and lack of movement. B) Hypothermia Rationale: The nurse should expect the infant to have alterations in temperature, including hypothermia or hyperthermia. Other manifestations can include vomiting, seizures, and nuchal rigidity. C) Sunken fontanel Rationale: The nurse should expect the infant to have a bulging or tense fontanel. D) Lethargy Rationale: The nurse should expect an infant to have marked irritability and restlessness.

A nurse is caring for a client who has chronic kidney disease and is taking hydrochlorothiazide. The nurse should monitor the client's laboratory values for which of the following findings? A) Hypokalemia B) Hyperphosphatemia C) Hypocalcemia D) Hypermagnesemia

A) Hypokalemia Rationale: The nurse should monitor the client's laboratory values for a decrease in potassium while the client is taking a thiazide diuretic due to the client's increased excretion of water and electrolytes. B) Hyperphosphatemia Rationale: The nurse should monitor the client's laboratory values for a decrease in phosphorus while the client is taking a thiazide diuretic. C) Hypocalcemia Rationale: The nurse should monitor the client's laboratory values for an increase in calcium while the client is taking a thiazide diuretic. D) Hypermagnesemia Rationale: The nurse should monitor the client's laboratory values for a decrease in magnesium while the client is taking a thiazide diuretic.

A nurse is assessing a client who has heart failure and reports chest pain and difficulty breathing. The nurse should identify that which of the following manifestations indicate the client is experiencing cardiogenic shock? (Select all that apply.) A) Hypotension B) Agitation C) Dry skin D) Tachypnea E) Polyuria

A) Hypotension Rationale: The nurse should identify that hypotension is a manifestation of cardiogenic shock. B) Agitation Rationale: The nurse should identify that agitation is a manifestation of cardiogenic shock. C) Dry skin Rationale: The nurse should identify that cool, clammy skin, rather than dry skin, is a manifestation of cardiogenic shock. D) Tachypnea Rationale: The nurse should identify that tachypnea is a manifestation of cardiogenic shock. E) Polyuria Rationale: The nurse should identify that a urine output of less than 0.5 to 1mL/kg/hr, rather than polyuria, is a manifestation of cardiogenic shock.

A nurse manager is facilitating conflict resolution between two nurses who disagree about the need to make a referral to social worker. Which of the following conflict management strategies should the nurse manager use? A) Implement soothing technique to permanently resolve the issue. B) Offer self to constructively facilitate communication. C) Encourage the nurses to email each other to resolve the issue. D) Send the nurses to behavior management training.

A) Implement soothing technique to permanently resolve the issue. Rationale: The nurse manager should use soothing technique as a temporary solution when conflict resolution is not possible and until an objective discussion can occur at a later date. B) Offer self to constructively facilitate communication. Rationale: The nurse should offer self as an impartial third party to constructively facilitate communication between the nurses to resolve the conflict. C) Encourage the nurses to email each other to resolve the issue. Rationale: The nurse manager should attempt to have the nurses meet face-to-face to communicate and resolve conflicts. D) Send the nurses to behavior management training. Rationale: The nurse manager should reserve behavior management for dysfunctional conflict and to help the nurses learn how to settle conflict responsibly.

A nurse is the change agent for instituting a new facility policy. After gathering data related to the change, which of the steps of change theory should the nurse take next? A) Implement the new strategies for the change gradually. B) Determine the level of the staff motivation for the change. C) Create strategies to implement the change. D) Provide support and reinforcement for the effective implementation of the change.

A) Implement the new strategies for the change gradually. Rationale: The nurse should implement the new strategies for the change gradually to overcome resistance to a new policy change. However, evidence-based practice indicates that there is another action the nurse should take before this step. B) Determine the level of the staff motivation for the change. Rationale: Evidence-based practice indicates the nurse should next determine the level of staff motivation for the change with the implementation of a new policy to reduce stress and facilitate the change. C) Create strategies to implement the change. Rationale: The nurse should create strategies to implement the change to facilitate staff support for the implementation of a new policy. However, evidence-based practice indicates that there is another action the nurse should take before this step. D) Provide support and reinforcement for the effective implementation of the change. Rationale: The nurse should provide support and reinforcement after the change has occurred to prevent ineffective implementation of the new policy and a return to the previous standard of client care. However, evidence-based practice indicates that there is another action the nurse should take before this step.

A charge nurse is preparing an education session for newly licensed nurses about the purpose of incident reports in a blameless culture. Which of the following information should the charge nurse include? A) Incident reports are used to reduce future preventable adverse events. B) Incident reports are provided to attorneys in the event of litigation. C) Incident reports are used to determine fault. D) Incident reports document the nurse's subjective interpretation of an event.

A) Incident reports are used to reduce future preventable adverse events. Rationale: The nurse should include that incident reports are directed to the risk manager to establish guidelines that reduce future preventable adverse events. B) Incident reports are provided to attorneys in the event of litigation. Rationale: The nurse should include that incident reports are not a part of a client's medical record and are not provided to attorneys. C) Incident reports are used to determine fault. Rationale: The nurse should include that incident reports are not used to place blame or determine fault. Rather, they are used to establish guidelines that reduce future preventable adverse events. D) Incident reports document the nurse's subjective interpretation of an event. Rationale: The nurse should include that incident reports should not contain subjective comments. Information in the report is restricted to objective observations and facts.

A nurse manager is teaching a unit nurse about case management. Which of the following information should the nurse manager include in the teaching about the role of the nurse as a case manager? A) Independently manages the care of the client B) Limited to inpatient care settings due to length of stay C) Advocates for services the client needs D) Provides direct client care to manage client outcomes

A) Independently manages the care of the client Rationale: A nurse case manager collaboratively manages care of the client with the interprofessional health care team to plan, facilitate, and advocate for the best options and services available to the client for extended care following discharge. B) Limited to inpatient care settings due to length of stay Rationale: A nurse case manager's role can extend to outpatient settings and is not limited to the inpatient environment because of the shortened length of stay in acute care. C) Advocates for services the client needs Rationale: A nurse case manager's role is to advocate for services needed and available resources to meet the client's needs. D) Provides direct client care to manage client outcomes Rationale: A nurse case manager uses critical pathways and nursing care plans, rather than providing direct client care, to manage expected client outcomes in a specific timeframe.

A nurse manager notices that he has exceeded the amount of money allocated for labor costs for the quarter. Which of the following actions should the nurse manager take? A) Involve staff nurses in budget planning. B) Ask case management to increase client length of stay. C) Increase the number of assistive personnel on each shift. D) Schedule additional training sessions on prioritizing client care.

A) Involve staff nurses in budget planning. Rationale: The nurse manager should involve staff nurses in the budget planning to promote awareness of the costs of staffing a unit and encourage cost-effective care. B) Ask case management to increase client length of stay. Rationale: The nurse manager should identify that decreased client length of stay reduces health care cost. C) Increase the number of assistive personnel on each shift. Rationale: The nurse manager should schedule staff based on client needs to avoid overstaffing. D) Schedule additional training sessions on prioritizing client care. Rationale: The nurse manager should postpone additional training sessions at this time to avoid increasing the labor budget's deficit.

A nurse in an emergency department is assessing a toddler and notes linear bruising across her buttocks. The guardian reports that the child was disciplined with a wooden spoon by a day care worker. Which of the following actions should the nurse take? A) Isolate the child from her guardian to determine the validity of the report. B) Ask the nurse manager to take custody of the child. C) Request the charts of other children from the same day care to review for possible abuse. D) Notify the local authorities of suspected abuse.

A) Isolate the child from her guardian to determine the validity of the report. Rationale: The nurse should not isolate the child from the guardian to determine the validity of the report. While it is important for the nurse to interview the child and guardian separately, isolation is not required. B) Ask the nurse manager to take custody of the child. Rationale: The nurse should not ask the nurse manager to take custody of the child. Only certified foster parents are allowed to take custody of the child and this decision is made by the local Department of Human Services. C) Request the charts of other children from the same day care to review for possible abuse. Rationale: The nurse should not request the charts of other children from the same day care to review for possible abuse due to HIPAA laws. D) Notify the local authorities of suspected abuse. Rationale: All nursing personnel are required to notify local authorities of suspected abuse and child maltreatment. Failure to do so can result in civil and criminal penalties.

A nurse is reviewing the laboratory values of a client who is in hypovolemic shock. Which of the following findings should the nurse expect? A) Lactic acid 5 mg/dL B) PaCO2 40 mm Hg C) PaO2 90 mm Hg D) pH level 7.25

A) Lactic acid 5 mg/dL Rationale: The nurse should expect laboratory findings for a client who is in hypovolemic shock to reflect metabolic acidosis, including an elevated lactic acid level. A lactic acid level of 5 mg/dL is within the expected reference range. B) PaCO2 40 mm Hg Rationale: The nurse should expect the client's laboratory values to reflect metabolic acidosis, including an elevated PaCO2 level. A PaCO2 of 40 mm Hg is within the expected reference range. C) PaO2 90 mm Hg Rationale: The nurse should expect the client's laboratory values to reflect metabolic acidosis, including a decreased PaO2 level. A PaO2 level of 90 mm Hg is within the expected reference range. D) pH level 7.25 Rationale: The nurse should expect the client's laboratory values to reflect metabolic acidosis. The client's pH level is decreased due to insufficient tissue perfusion. A pH level of 7.25 is below the expected reference range.

A nurse is caring for a client who has a new diagnosis of heart failure. Which of the following actions should the nurse take first? A) Monitor the client's electrolyte levels. B) Evaluate the client's breath sounds. C) Administer a diuretic to the client. D) Obtain the client's nutritional history.

A) Monitor the client's electrolyte levels. Rationale: The nurse should monitor the client's electrolyte levels to determine if there is an imbalance. However, there is another action the nurse should take first. B) Evaluate the client's breath sounds. Rationale: When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to assess the client's breath sounds to evaluate her respiratory status. C) Administer a diuretic to the client. Rationale: The nurse should administer a diuretic to the client to reduce fluid volume. However, there is another action the nurse should take first. D) Obtain the client's nutritional history. Rationale: The nurse should obtain the client's nutritional history to determine her sodium intake. However, there is another action the nurse should take first.

A nurse is caring for a group of postpartum clients. Which of the following tasks should the nurse delegate to an assistive personnel? A) Monitor the reflexes of a client who has preeclampsia. B) Measure the urine output of a client who is receiving magnesium sulfate. C) Check the pain level of a client who has received analgesia. D) Reinforce teaching about perineal care for a client who had an episiotomy.

A) Monitor the reflexes of a client who has preeclampsia. Rationale: Monitoring reflexes is an assessment, which requires use of the nursing process. Therefore, this task is not within the range of function of an assistive personnel. B) Measure the urine output of a client who is receiving magnesium sulfate. Rationale: Measuring the urine output of a client who is receiving magnesium sulfate does not require use of the nursing process and is within the range of function of an assistive personnel. C) Check the pain level of a client who has received analgesia. Rationale: Checking the pain level of a client who has received analgesia is an assessment, which requires use of the nursing process. Therefore, this task is not within the range of function of an assistive personnel. D) Reinforce teaching about perineal care for a client who had an episiotomy. Rationale: Reinforcing teaching about perineal care for a client who had an episiotomy requires the use of clinical judgment and critical thinking. Therefore, this task is not within the range of function of an assistive personnel.

A nurse is caring for a client who has sepsis and has developed disseminated intravascular coagulation (DIC). Which of the following actions should the nurse take? A) Obtain the client's rectal temperature every 2 hr. B) Perform mouth care for the client using glycerin swabs. C) Administer anticoagulants to the client. D) Monitor the client's breath sounds every 8 hr.

A) Obtain the client's rectal temperature every 2 hr. Rationale: The nurse should avoid obtaining rectal temperatures due to the increased risk for rectal bleeding. B) Perform mouth care for the client using glycerin swabs. Rationale: The nurse should avoid using glycerin swabs due to their drying effects on the mucosa, which increases the risk for bleeding. C) Administer anticoagulants to the client. Rationale: The nurse should administer anticoagulants to limit the clotting. D) Monitor the client's breath sounds every 8 hr. Rationale: The nurse should monitor the client's breath sounds at least every 2 to 4 hr to assess for crackles and other manifestations of fluid overload.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take? A) Place the infant on airborne precautions. B) Maintain the infant's oxygen saturation at 88%. C) Administer IV immunoglobulin to the infant. D) Offer fluid via oral syringe to the infant every 10 min.

A) Place the infant on airborne precautions. Rationale: The nurse should place an infant who has RSV on droplet, contact, and standard precautions. B) Maintain the infant's oxygen saturation at 88%. Rationale: The nurse should maintain oxygen saturation greater than or equal to 90% for an infant who has RSV. C) Administer IV immunoglobulin to the infant. Rationale: The nurse should administer IV immunoglobulin to an infant who has Kawasaki disease. D) Offer fluid via oral syringe to the infant every 10 min. Rationale: The nurse should offer 5 to 10 mL of fluid via oral medication syringe to the infant every 10 min to maintain hydration in an infant who has RSV. Infants who have RSV have difficulty feeding due to increased secretions.

A nurse in a provider's office is caring for an older adult client who recently had a total knee arthroplasty. Then client requires short-term rehabilitation in a skilled nursing facility. Which of the following parts of Medicare should the nurse expect to cover the majority of the cost of treatment? A) Part A B) Part B C) Part C D) Part D

A) Part A Rationale: The nurse should expect Medicare Part A to cover the cost of the client's treatment because this plan covers acute care, short-term rehabilitation in a skilled nursing facility, rehabilitation in the client's home, and most of the cost of hospice care. B) Part B Rationale: Medicare Part B provides insurance coverage for many services provided to clients on an outpatient basis, such as office visits to primary providers. C) Part C Rationale: Medicare Part C, also called the Medicare Advantage Plans, supplements Medicare Parts A and B and might provide a cost savings to clients. Nonprimary care without a referral is not covered, and all costs are out-of-pocket. D) Part D Rationale: Medicare Part D provides prescription drug benefits. It is an elective plan with out-of-pocket premiums and copayments. All clients who have Medicare are eligible to enroll.

A community health nurse is teaching a newly licensed nurse about the types of psychiatric health care settings available in the community. Which of the following should the nurse identify as a primary care setting? A) Partial hospitalization program B) Locked inpatient unit C) Day treatment program D) Outpatient counseling clinic

A) Partial hospitalization program Rationale: Partial hospitalization programs provide clients with short, intensive mental health treatments similar to inpatient treatments. However, patients are allowed to return home each day. Typically, the program lasts 5 to 6 hr per day. B) Locked inpatient unit Rationale: The most acute treatment facility for clients seeking mental health care is a locked inpatient unit. C) Day treatment program Rationale: Day treatment programs provide clients with behavioral regulation and social skills development. However, patients are allowed to return home each day. D) Outpatient counseling clinic Rationale: Outpatient counseling clinics are primary care settings that provide strategies for clients to prevent or delay mental health issues.

A public health nurse is teaching an educational session about emergency preparedness. The nurse should include that which of the following actions is part of the preparedness phase of the disaster management cycle? A) Participate in mass casualty exercises. B) Participate in triage of injured community members. C) Provide psychosocial support to impacted individuals. D) Provide information about the scope of the disaster.

A) Participate in mass casualty exercises. Rationale: The nurse should include in the teaching that participating in mass casualty exercises is part of the preparedness phase of the disaster management cycle. Participating in these exercises tests the effectiveness of the disaster plan. B) Participate in triage of injured community members. Rationale: The nurse should include in the teaching that participating in triage of injured community members is part of the response phase of the disaster management cycle. C) Provide psychosocial support to impacted individuals. Rationale: The nurse should include in the teaching that providing psychosocial support to impacted individuals is part of the recovery phase of the disaster management cycle. D) Provide information about the scope of the disaster. Rationale: The nurse should include in the teaching that providing information about the scope of the disaster is part of the response phase of the disaster management cycle.

A nurse is developing a plan of care for a client who has sustained burns to the lower half of his body and is to receive hydrotherapy. Which of the following actions should the nurse include in the plan? A) Perform hydrotherapy for the client at least four times each day. B) Immerse the client in a whirlpool of warm water. C) Use forceps and scissors to remove the loose, dead tissue from the client's wound. D) Leave any blisters that form on the client's burn intact.

A) Perform hydrotherapy for the client at least four times each day. Rationale: The nurse should plan to perform hydrotherapy one to two times daily to clean and debride the wound. B) Immerse the client in a whirlpool of warm water. Rationale: The nurse should perform hydrotherapy by placing the client on a special shower table and washing small areas of the client's wound. Immersion in a whirlpool or tub is no longer performed due to the increased risk for infection. C) Use forceps and scissors to remove the loose, dead tissue from the client's wound. Rationale: The nurse should use scissors and forceps to remove loose, dead tissue from the client's wound during hydrotherapy to promote healing. D) Leave any blisters that form on the client's burn intact. Rationale: The nurse can leave small blisters intact to serve as a protective barrier that promotes healing. However, the nurse should open large blisters and thoroughly clean the area with mild soap and water.

A nurse is caring for a client who has acute respiratory distress syndrome and is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent the client from acquiring ventilator-associated pneumonia? A) Perform mouth care for the client every 6 hr. B) Maintain head of the client's bed at 15°. C) Turn the client every 4 hr. D) Check the client's need for suctioning every 2 hr.

A) Perform mouth care for the client every 6 hr. Rationale: The nurse should perform mouth care for the client every 2 hr to prevent aspiration and ventilator-associated pneumonia. B) Maintain head of the client's bed at 15°. Rationale: The nurse should maintain the head of the client's bed at 30° to prevent aspiration and ventilator-associated pneumonia. C) Turn the client every 4 hr. Rationale: The nurse should turn the client every 2 hr to prevent aspiration and ventilator-associated pneumonia. D) Check the client's need for suctioning every 2 hr. Rationale: The nurse should check the client's need for suctioning every 2 hr to prevent aspiration and ventilator-associated pneumonia.

A nurse is planning care for a client who has acute viral hepatitis. Which of the following interventions should the nurse include in the plan? A) Place the client on complete bed rest. B) Provide the client with a high-carbohydrate diet. C) Administer acetaminophen if the client has pain. D) Allow the client to use the same towels as family members.

A) Place the client on complete bed rest. Rationale: The nurse should plan to allow the client to ambulate and then have periods of rest to decrease the client's liver metabolic demands and increase the blood supply to the client's liver to promote healing. B) Provide the client with a high-carbohydrate diet. Rationale: The nurse should plan to provide the client with a high-carbohydrate and high-calorie diet with moderate fat and protein to promote healing. C) Administer acetaminophen if the client has pain. Rationale: The nurse should administer a pain medication other than acetaminophen, which is metabolized through the liver and can increase the liver's metabolic demands, which damages the liver further and slows healing. D) Allow the client to use the same towels as family members. Rationale: The nurse should instruct the client not to share towels with family members to avoiding spreading the viral hepatitis.

A nurse manager identifies that the number of client medication administration errors on the unit has increased. When creating a cause-and-effect chart, which of the following information should the nurse manager include? A) Possible reasons for the medication errors B) Number of medication errors per month C) The staff responsible for reporting medication errors D) The facility's policy for preventing medication errors

A) Possible reasons for the medication errors Rationale: The nurse manager should identify and include possible reasons for the occurrence of medication errors when creating a cause and effect chart. This data assists in the prevention of future medication errors. B) Number of medication errors per month Rationale: The nurse manager should include the number of medication errors per month when creating a run chart for quality improvement. C) The staff responsible for reporting medication errors Rationale: The nurse manager should include the staff responsible for reporting medication errors when creating a flow chart for quality improvement. D) The facility's policy for preventing medication errors Rationale: The nurse manager should review the facility's policy for preventing medication errors when determining the need to revise clinical protocols. This step occurs after reviewing the cause-and-effect chart.

A nurse is teaching about managing care with the family of a client who has Parkinson's disease and takes dopamine. Which of the following information should the nurse include in the teaching? A) Provide a low-protein diet for the client. B) Allow the client to perform ADLs. C) Schedule appointments for the client early in the morning. D) Monitor the client for an elevated blood pressure.

A) Provide a low-protein diet for the client. Rationale: The nurse should instruct the family to provide the client with a high-protein, high-carbohydrate diet to maintain his weight. B) Allow the client to perform ADLs. Rationale: The nurse should instruct the family to allow the client to perform ADLs and mobility skills to promote and maintain independence for as long as possible. C) Schedule appointments for the client early in the morning. Rationale: The nurse should instruct the family to schedule the client's appointments late in the morning to prevent rushing and fatigue. D) Monitor the client for an elevated blood pressure. Rationale: The nurse should instruct the family to monitor the client for orthostatic hypotension, which can be caused by the client's dopamine. The nurse should include that hallucinations and confusion are other adverse effects of this medication.

A nurse is caring for a client who has Parkinson's disease. Which of the following actions should the nurse take to promote the client's mobility? A) Provide the client with a cool bath. B) Encourage the client to jog on the treadmill daily. C) Instruct the client to perform range-of-motion exercises. D) Assist the client to walk with a narrow-based gait.

A) Provide the client with a cool bath. Rationale: The nurse should provide the client with a warm bath and therapeutic massage to relax her muscles, which relieves muscle spasms and rigidity. These interventions promote mobility. B) Encourage the client to jog on the treadmill daily. Rationale: The nurse should encourage the client to walk or ride a stationary bicycle. A client who has Parkinson's disease can have shuffling of the gait. Jogging increases the client's risk for falling. C) Instruct the client to perform range-of-motion exercises. Rationale: The nurse should instruct the client to perform stretching and range-of-motion exercises to promote mobility. Exercising and walking help to delay the progression of the disease. D) Assist the client to walk with a narrow-based gait. Rationale: The nurse should assist the client to walk with a wide-based gait, which gives the client more balance and helps prevent falls.

A nurse is caring for a client who has had a myocardial infarction and suspects cardiogenic shock. The nurse should monitor for which of the following manifestations? A) Pulmonary congestion B) Bradycardia C) Hypertension D) Bounding pulse

A) Pulmonary congestion Rationale: The nurse should monitor the client for pulmonary congestion as an indication of cardiogenic shock. Pulmonary congestion is a result of decreased cardiac output due to damage to the cardiac muscle. B) Bradycardia Rationale: The nurse should monitor for tachycardia as an indication of cardiogenic shock. C) Hypertension Rationale: The nurse should monitor for hypotension as an indication of cardiogenic shock. D) Bounding pulse Rationale: The nurse should monitor for a thready pulse as an indication of cardiogenic shock.

A nurse is assessing a client who has sepsis with systemic inflammatory response syndrome (SIRS). Which of the following findings should the nurse expect? (select all that apply.) A) Pulse 100/min B) WBC 14,000/mm3 C) Systolic blood pressure 150 mm Hg D) Platelet count 70,000/mm3 E) Hyperactive bowel sounds

A) Pulse 100/min Rationale: The nurse should expect the client to have an accelerated heart rate of greater than 90/min. B) WBC 14,000/mm3 Rationale: The nurse should expect the client to manifest a WBC greater than 12,000/mm3, which can indicate systemic infection. C) Systolic blood pressure 150 mm Hg Rationale: The nurse should expect the client to have a systolic blood pressure of less than 90 mm Hg due to a compensatory response that causes vasodilation. D) Platelet count 70,000/mm3 Rationale: The nurse should expect the client to have a platelet count of less than 100,000/mm3 due to formation of microthrombi consuming much of the available platelets and clotting factors. E) Hyperactive bowel sounds Rationale: The nurse should expect the client to have absent bowel sounds due to decreased circulation, cell anoxia, and cell death leading to organ failure.

A nurse is reviewing the ECG strip of a client who is experiencing angina. Which of the following abnormal characteristics should the nurse expect to find? A) ST elevation B) Prolonged QRS complex C) Absent P wave D) T wave inversion

A) ST elevation Rationale: The nurse should identify that a client who had a myocardial infarction can experience an ST elevation. ST depression can be the result of ischemia of the heart caused by angina. B) Prolonged QRS complex Rationale: The nurse should identify that a prolonged QRS complex indicates that the electrical impulse of the client's heart is of ventricular origin with an aberrant conduction deviating from the expected pattern, which can indicate a left or right bundle branch block. C) Absent P wave Rationale: The nurse should identify that absent P waves, or no discernible P waves, can be the result of atrial fibrillation. This occurs when the rate of the heart is rapid and irregular, which reduces the ventricular filling time and decreases stroke volume and atrial kick. D) T wave inversion Rationale: The nurse should identify that an inverted T-wave indicates ischemia of the heart as a result of angina.

A nurse is caring for a client who has a referral for occupational therapy. The nurse should identify on the referral form that the client needs assistance with which of the following? A) Shoulder range of motion B) Self-grooming activities C) Finding community resources D) Communication skills

A) Shoulder range of motion Rationale: The nurse should provide information regarding a client's need for assistance with shoulder range of motion on a referral form for physical therapy. B) Self-grooming activities Rationale: The nurse should provide information regarding a client's need for assistance with self-grooming on a referral form for occupational therapy. The occupational therapist can assist and teach the client to become independent with activities of daily living such as grooming, bathing, dressing, and eating. C) Finding community resources Rationale: The nurse should provide information regarding a client's need for assistance with finding community resources on a referral form for social services. D) Communication skills Rationale: The nurse should provide information regarding a client's need for assistance with communication with others on a referral form for speech-language pathology.

A nurse is teaching a group of assistive personnel about prevention pressure ulcers. Which of the following images should the nurse include in the teaching? A) Side-lying B) Fowler's C) Semi Fowler's with heels raised D) Wheelchair with a cushion

A) Side-lying Rationale: The nurse should teach the assistive personnel to avoid positioning the client in the lateral position directly on the trochanter, but should tilt the client back with pillow support and pillows between the legs at the knees. Lying directly on the trochanter or having the knees against each other can cause excess pressure from bony prominences on blood vessels at the point of contact and lead to a pressure ulcer. B) Fowler's Rationale: The nurse should teach the assistive personnel to avoid positioning the head of bed at greater than 30° for an extended period of time. Shearing can occur from the client sliding down in bed causing the client's skin to remain stationary while the underlying tissue shifts, decreasing blood supply to the skin tissue, which can lead to a pressure ulcer. C) Semi Fowler's with heels raised Rationale: The nurse should teach the assistive personnel to place a pillow or blankets under the client's legs or ankles to prevent the heel from rubbing on the bed linens and causing a friction rub that can lead to a pressure ulcer. The head of the bed should be positioned at less than 30° to prevent shearing pressure. D) Wheelchair with a cushion Rationale: The nurse should teach the assistive personnel to not place a donut-shaped pillow in a wheelchair or chair because the pillow can compress and damage capillaries and increase tissue breakdown, which can lead to pressure ulcers.

A nurse manager is attempting to resolve a conflict by asking the nurses to focus on the positive, rather than the negative, aspects of the situation. Which of the following conflict resolution strategies is the charge nurse using? A) Smoothing B) Collaborating C) Accommodating D) Competing

A) Smoothing Rationale: The nurse manager is using the conflict resolution strategy of smoothing. Smoothing occurs when conflicting parties are asked to focus on positive, rather than negative, aspects of a situation. This strategy minimizes the emotional component of the conflict. B) Collaborating Rationale: Collaborating occurs when all conflicting parties put aside their original goals and work as a team to establish a common goal. C) Accommodating Rationale: Accommodating occurs when one party sacrifices his beliefs and allows the other party to win. The underlying conflict is not resolved. D) Competing Rationale: Competing occurs when one party pursues a goal regardless of the cost to others. This strategy causes anger and frustration in the losing party.

A nurse is reviewing the medical record of a male adult client who was admitted with angina. Which of the following findings should indicate to the nurse the client might have experienced a myocardial infarction? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Exhibit 1:History and Physical ​48-year-old male who has hypertension and hypothyroidism Family history of acute coronary syndrome and colon cancer Client reports chest pain lasting less than 15 minutes. Exhibit 2: Graphic Record Vital signs: Temperature 38.9° C (102° F) Heart rate 88/min, regular Respiratory rate 20/min Blood pressure 132/82 mm Hg Oxygen saturation rate: 95% on 2 L Exhibit 3: Diagnostic Results Troponin T 1.0 ng/mL Troponin I 1.2 ng/mL CK 180 units/L CK-MB 8.2 ng/L A) Temperature B) Oxygen saturation C) Chest pain D) Blood pressure

A) Temperature Rationale: The nurse should identify that the client's elevated temperature can be an indication of a myocardial infarction. A client might have an elevated temperature for several days following the infarction because this is the body's inflammatory response to myocardial necrosis. B) Oxygen saturation Rationale: An oxygen saturation level that is greater than or equal to 95% with 2 L of oxygen via nasal cannula is an indication of adequate blood oxygen saturation levels. However, the nurse should continue to monitor the client's pulmonary status for heart failure. C) Chest pain Rationale: Chest pain that lasts longer than 30 min might indicate a myocardial infarction. However, experiencing chest pain for 15 min or less is an indication of angina. D) Blood pressure Rationale: A blood pressure of 132/82 mm Hg is within the expected reference range. Therefore, this is not an indiction of a myocardial infarction.

A nurse is assessing a client who has sepsis. For which of the following findings should the nurse notify the rapid response team? A) Temperature 38° C (100.5° F) B) Platelets 150,000/mm3 C) Systolic blood pressure 88 mm Hg D) Capillary refill 2 seconds

A) Temperature 38° C (100.5° F) Rationale: The nurse should notify the rapid response team if the client's temperature is greater than 38.3° C (101° F). B) Platelets 150,000/mm3 Rationale: The nurse should notify the rapid response team if the client's platelet count is less than 100,000/mm3. C) Systolic blood pressure 88 mm Hg Rationale: The nurse should notify the rapid response team if the client's systolic blood pressure is less than 90 mm, which can be an indication of progression to sepsis with systemic inflammatory response syndrome. D) Capillary refill 2 seconds Rationale: The nurse should notify the rapid response team if the client's capillary refill is decreased. A capillary refill time of 2 seconds is within the expected reference range.

A nurse is having a disagreement with a coworker about a client assignment. When following the chain of command, which of the following individuals should the nurse contact to discuss the conflict? A) The client's provider B) The facility risk manager C) The chief nursing officer D) The charge nurse

A) The client's provider Rationale: The nurse should communicate with the client's provider to report changes in the client's condition and discuss treatment. B) The facility risk manager Rationale: The nurse should communicate with the facility risk manager to report client safety incidents. C) The chief nursing officer Rationale: The nurse should not contact the chief nursing officer first, because this action does not follow the levels of the chain of command. D) The charge nurse Rationale: When following the chain of command, the nurse should communicate with his immediate supervisor about any questions and concerns he has, including a conflict with a coworker.

A nurse is teaching a family member of a client who has a new diagnosis of disseminated intravascular coagulation (DIC). The nurse should include that DIC is a disorder that alters which of the following? A) The immune system B) The blood-clotting process C) Musculoskeletal function D) Electrolyte balance

A) The immune system Rationale: DIC is a disorder of the blood-clotting process and does not alter the immune system. B) The blood-clotting process Rationale: DIC is a disorder of the blood-clotting process. Widespread clotting of blood vessels and major organs can result in depletion of clotting factors and cause hemorrhage. C) Musculoskeletal function Rationale: DIC is a disorder of the blood-clotting process and does not alter musculoskeletal function. D) Electrolyte balance Rationale: DIC is a disorder of the blood-clotting process and does not alter electrolyte balance.

A charge nurse is delegating client care assignments for a group of nurses. The charge nurse should identify that which of the following factors is the priority when making assignments? A) The number of clients on the unit B) Available technology C) The level of intensity of care D) Experience of the nursing staff

A) The number of clients on the unit Rationale: The charge nurse should consider the number of clients on the unit when delegating assignments to determine the number of nursing staff needed on the unit. However, there is another factor the charge nurse should consider first. B) Available technology Rationale: The charge nurse should compare available technology to the nursing staff's ability to use the technology when delegating assignments. However, there is another factor the charge nurse should consider first. C) The level of intensity of care Rationale: The first action the charge nurse should take using the nursing process is to assess the level of intensity of client care or acuity when delegating assignments. Acuity level is a categorization of client care needs and the degree of care needed. The higher the acuity level, the more intense and complex the client care is. D) Experience of the nursing staff Rationale: The charge nurse should consider the experience of the nursing staff, educational preparedness, and clinical judgment of the nurses when delegating assignments. However, there is another factor the charge nurse should consider first.

A nurse is caring for clients on a medical-surgical unit. Which of the following actions by the nurse demonstrates the professional characteristic of human dignity? A) The nurse treats each of his assigned clients with equal respect. B) The nurse offers to help overwhelmed coworkers with client care. C) The nurse respects the right of a client who has chronic kidney disease to choose to stop dialysis. D) The nurse contacts an interpreter for a client who does not speak the same language as the nurse.

A) The nurse treats each of his assigned clients with equal respect. Rationale: This action by the nurse is an example of the professional characteristic of human dignity, which includes treating all clients equally regardless of medical history or background. B) The nurse offers to help overwhelmed coworkers with client care. Rationale: This action by the nurse is an example of the professional characteristic of altruism. C) The nurse respects the right of a client who has chronic kidney disease to choose to stop dialysis. Rationale: This action by the nurse is an example of the professional characteristic of autonomy. D) The nurse contacts an interpreter for a client who does not speak the same language as the nurse. Rationale: This action is an example of the professional characteristic of social justice.

A client asks a nurse how to apply for Medicaid services. The nurse should refer the client to which of the following agencies? A) The state welfare office B) The local Social Security Administration office C) The local health department D) The state insurance department

A) The state welfare office Rationale: The nurse should refer the client to the state welfare office to get information about applying for Medicaid services. Medicaid funds are distributed to states to provide assistance for older adults, individuals with disabilities, and families who have dependent children. B) The local Social Security Administration office Rationale: The nurse should refer the client to the local Social Security Administration office for information regarding Medicare. C) The local health department Rationale: The nurse should refer the client to the local health department for programs such as Women, Infants, and Children (WIC). D) The state insurance department Rationale: The nurse should refer the client to the state insurance department for assistance with obtaining private insurance.

A nurse is reviewing the laboratory values of a client who has Addison's disease. Which of the following findings should the nurse expect? A) Total calcium 8.2 mEq/L B) Potassium 6.2 mEq/L C) Blood glucose 320 mg/dL D) Sodium 148 mEq/L

A) Total calcium 8.2 mEq/L Rationale: A client who has Addison's disease is at risk for hypercalcemia due to a lack of cortisol concentration levels, which leads to a fluid and electrolyte imbalance. A total calcium level of 8.2 mEq/L is below the expected reference range. B) Potassium 6.2 mEq/L Rationale: A client who has Addison's disease will have a potassium level that rapidly increases due to lack of cortisol concentration levels, which leads to a fluid and electrolyte imbalance. A potassium level of 6.2 mEq/L is above the expected reference range and is an expected finding for a client who has Addison's disease. C) Blood glucose 320 mg/dL Rationale: A client who has Addison's disease is at risk for hypoglycemia due to an abnormal regulation of glucose from lack of cortisol concentration levels. A blood glucose level of 320 mg/dL is above the expected reference range. D) Sodium 148 mEq/L Rationale: A client who has Addison's disease is at risk for hyponatremia due to a lack of cortisol concentration levels, which leads to a fluid and electrolyte imbalance. A sodium level of 148 mEq/L is above the expected reference range.

A community health nurse is concerned about the lack of health care services available to low-income communities. Which of the following actions should the nurse take to act as an effective health care legislation advocate? A) Volunteer at a local clinic. B) Conduct a community health assessment. C) Join a professional nursing organization. D) Assist eligible clients to sign up for the Women, Infants, and Children (WIC) program.

A) Volunteer at a local clinic. Rationale: Volunteering at a local clinic allows nurse to fulfill a caregiver role. However, this action does not directly affect legislation. B) Conduct a community health assessment. Rationale: Conducting a community health assessment allows the nurse to understand the needs in the community. However, this action does not directly affect legislation. C) Join a professional nursing organization. Rationale: Joining a professional nursing organization can allow nurses to have a collective voice when advocating for legislative policies. D) Assist eligible clients to sign up for the Women, Infants, and Children (WIC) program. Rationale: Assisting clients to sign up for WIC addresses individual needs. However, this does not directly affect legislation.

A nurse is caring for a client who has chronic kidney disease. Which of the following actions should the nurse take to manage the client's fluid volume? A) Weigh the client twice per day using different scales. B) Encourage the client to drink most of the allotted fluids in the morning. C) Monitor the client's blood pressure every 4 hr. D) Assess the client for the presence of edema every 8 hr.

A) Weigh the client twice per day using different scales. Rationale: According to research-based care, the nurse should weigh the client once daily at the same time each day. The nurse should use the same scale daily and ensure the client is wearing the same amount of clothing each time. B) Encourage the client to drink most of the allotted fluids in the morning. Rationale: According to research-based care, the nurse should encourage the client to keep his fluid intake within the prescribed restricted amount and to distribute the intake evenly throughout 24 hr. C) Monitor the client's blood pressure every 4 hr. Rationale: According to research-based care, the nurse should monitor the client's blood pressure at least every 4 hr. An elevated blood pressure can indicate fluid volume overload, so the nurse should report this finding to the provider. D) Assess the client for the presence of edema every 8 hr. Rationale: According to research-based care, the nurse should assess the client for manifestations of fluid volume overload, including the presence of dependent edema, decreased urine output, and decreased oxygen saturation, at least every 4 hr.