HESI NCLEX Practice Fundamentals

What is the role of a case manager in a healthcare organization? To delegate work on the unit suitably To follow up with the client after discharge To provide direct care for the client at the bedside To unite the strategic direction of the organization

To follow up with the client after discharge A case manager is an advanced practice nurse who coordinates a client's acute care in the hospital and follows up with the client after discharge. A nurse manager delegates work appropriately to the nursing staff on the unit. A registered nurse provides direct care to the client at the bedside. The nurse executive is often the vice president or strategic director of nursing in a healthcare organization.

A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse? "Why are you always laughing?" "Your laughter is a cover for your fear." "Does it help to joke about your illness?" "The person who laughs on the outside cries on the inside."

"Does it help to joke about your illness?" The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "alternative medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? "Hospital policies should put a stop to this." "Everyone should conform to the prevailing culture." "Nontraditional approaches to health care can be beneficial." "You are right because they may have a negative impact on people's health."

"Nontraditional approaches to health care can be beneficial." Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

Which description is most appropriate for the family centered care approach? The nursing care is focused on the client as an individual. A collaborative plan of care is developed to achieve optimal health. The healthcare provider is the expert in developing a plan of care. The nursing care is based solely on standards of practice.

A collaborative plan of care is developed to achieve optimal health. Family-centered care is commonly used to describe optimal health care as experienced by families. The term is frequently accompanied by terms such as "partnership," "collaboration," and families as "experts" to describe the process of care delivery. Family care addresses the family versus one individual. The healthcare provider collaborates with the family to develop a plan of care. Evidence based standards of practice are incorporated into a collaborative family centered care plan. Standards are not the only guidelines considered in a family centered plan of care.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? Red blood cell count Sputum culture Arterial blood gas Total hemoglobin

Arterial blood gas Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

The nurse is verbally interviewing and taking a history of a client who was admitted to the hospital. Which phase of the nursing process is being used in this situation? Planning Evaluation Assessment Diagnosis

Assessment Assessment involves taking the history of and verbally interviewing a client. Planning is the phase of the nursing process that includes the development of a written document of expected outcomes. Evaluation is the phase of the process when the care plan is modified and updated. Diagnosis involves the documentation and validation of healthcare needs and priorities via verbal discussion with the client.

What is the most important skill of the nurse leader? Priority setting Time management Clinical decision making Clinical care coordination

Clinical care coordination The most important leadership skill for a nursing student is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components included in clinical care coordination.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? Contact an interpreter provided by the hospital. Contact the client's family member to translate for the client. Communicate with the client using Spanish phrases the nurse learned in a college course. Communicate with the client with the use of a hospital-approved Spanish dictionary.

Contact an interpreter provided by the hospital. Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? No special precautions are required. Cover the infected site with a dressing. Drape the client with a covering labeled biohazardous. Place a surgical mask on the client.

Cover the infected site with a dressing. Covering the infected site with a dressing will contain secretions and set up a barrier, thus decreasing the risk for transmission to others. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Draping the client with a sheet marked biohazardous does not protect the client's privacy. A wound infected with MRSA can be transmitted to others via contact, not the airborne route; thus a mask is unnecessary.

A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what? Decrease peristalsis Minimize electrolyte imbalance Decrease bacteria in the intestines Treat inflammation caused by the malignancy

Decrease bacteria in the intestines To decrease the possibility of contamination, the bacteria count in the colon is lowered with antibiotics before surgery. Preoperative antibiotics do not have an effect on peristalsis, electrolyte balance, or treating inflammation.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the room. Implement contact precautions and post appropriate signage. After finishing with patient care, remove the gown first and then remove the gloves.

Don an N95 respirator mask before entering the room. A N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply. Dry cleaners Dye workers Lathe operators Hospital workers Agricultural workers

Dry cleaners Dye workers Dry cleaners and dye workers are at high risk of developing dermatitis due to exposure to substances such as solvents and dye stuffs. Lathe operators are at high risk of developing cancer. Hospital workers are at greater risk of latex allergies. Agricultural workers are at high risk of skin cancer.

When caring for a client with venous insufficiency, the nurse would implement which nursing measure? Apply abdominal girdle as needed. Remove compression stockings for client ambulation. Elevate the client's legs above heart level. Keep the upper extremities elevated.

Elevate the client's legs above heart level. Venous insufficiency occurs when vascular damage impedes the body's ability to move blood from the legs toward the heart. This causes blood to pool in the legs, where it can cause swelling; pain; and, in some cases, leaking fluid in the skin or ulcers. Elevation of the legs above the level of the heart makes use of gravitational forces to drain blood through the veins toward the heart. Clients should not wear tight restrictive pants and should avoid wearing a girdle or garter, which may impede venous return. Compression stockings prevent blood pooling. Elevating the upper extremities will not decrease edema in lower extremities.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? Elevate the head of the bed between 30 and 45 degrees. Decrease flow rate at night. Check for residual daily. Irrigate regularly with warm tap water.

Elevate the head of the bed between 30 and 45 degrees. To prevent aspiration, the nurse should keep the head of the bed elevated between 30 and 45 degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of skin breakdown. Decreasing flow rate, checking residual, and irrigating regularly will not prevent aspiration.

What does the professional nurse consider to be the center of decision-making when providing client care? Ethics of care Nursing skills Analytical skills Research based practice

Ethics of care A professional nurse always follows the ethics of care and considers caring to be the center of decision-making. The nurse must know what behavior is ethically appropriate while caring for a client. A nurse's effectiveness in performing tasks is important to client care; however, client satisfaction comes from the effective dimension of care. Because ethics of care are unique to each client, the nurse should not base decision-making only on analytical skills. The nurse should not provide client care based only on intellectual principles or research knowledge. Caring is the most important factor because it considers client preferences and values.

Which professional standard does the nurse feel is most important for critical thinking? Logical thinking Evaluation criteria Accurate knowledge Relevant information

Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? Evaluation Explanation Interpretation Self-regulation

Explanation Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients? Analysis Inference Explanation Interpretation

Explanation Explanation requires knowledge and experience for choosing strategies for care of clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with an ordered data collection.

Which statement defines the term family resiliency? Family resiliency is the uniqueness of each family. Family resiliency is the ability of the family to cope with stressors. Family resiliency is the intrafamilial system of support and structure. Family resiliency is the ability of the family to transcend.

Family resiliency is the ability of the family to cope with stressors. Family resiliency is the ability of the family to cope with expected and unexpected stressors. Family diversity is the uniqueness of each family. Family durability is the interfamilial support system that extends beyond the walls of the household. The parents of this family may remarry or children may leave the home as adults, however, the family is capable of transcending inevitable lifestyle changes.

Which therapeutic communication technique is useful when the nurse and a client have a conversation and the client begins to repeat the conversation to himself or herself? Focusing Clarifying Paraphrasing Summarizing

Focusing Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps to check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.

Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? Activity theory Continuity theory Disengagement theory Gerotranscendence theory

Gerotranscendence theory The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? Primary nurse Nurse clinician Nurse coordinator Clinical nurse specialist

Primary nurse The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or healthcare provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. Clinical nurse specialist is a title given to a nurse specially prepared for one very specific clinical role. It requires a master's degree level of education.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? Provide perineal care. Turn and position the client. Give a complete bed bath. Document the bowel movement.

Provide perineal care. Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client? Touch Reminiscence Reality orientation Validation therapy

Reality orientation A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation. Touch is a therapeutic tool that helps to induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps to bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help a client in a confused state.

Which nursing practice is associated with the self-regulation skill? Reflecting on one's experience Reflecting on one's own behavior Supporting one's findings and conclusions Clarifying any data that one is uncertain about

Reflecting on one's experience Self-regulation involves reflecting on the nurse's experience. Evaluation involves reflecting on the nurse's own behavior. Explanation involves supporting findings and conclusions. Interpretation involves clarifying any data about which the nurse is uncertain.

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what? Restore the client's health. Promote the client's recovery. Relieve the client's discomfort. Support the client's significant others.

Relieve the client's discomfort. Palliative measures are aimed at relieving discomfort without curing the problem. A cure or recovery is not part of palliative care; with a terminal disease the other goals are unrealistic. Although support of significant others is indicated, palliative care is related directly to relieving the client's discomfort.

What should the community nurse teach about the risk of adolescent pregnancy? Risk for premature birth Risk for having a large baby Risk for chromosomal defects Risk for increased weight gain

Risk for premature birth The nurse should teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected from lack of nutrition, and exposure to alcohol, drugs, and tobacco.

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? Prioritize psychosocial needs over physical needs. Use the Nursing Outcomes Classification (NOC) only. Use nursing knowledge to plan outcomes and disregard client and family desires. Set priorities and outcomes using the client's and family input.

Set priorities and outcomes using the client's and family input. Outcomes should be set with the client and family, if feasible, just as priorities of interventions are considered with the client and family when possible. Physical needs should be met before psychosocial needs. Outcomes may be developed using two methods: writing specific outcome statements or choosing outcomes from the NOC.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse? The client's gag reflex has returned. The client is confused due to anesthesia. The client is nauseated and wants to vomit. The client's airway is becoming obstructed.

The client's gag reflex has returned. The ability to spit out the oral airway indicates that the normal gag reflex has returned, and the client can protect his or her airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit put the airway does not mean that the client is nauseated. Oral airway is meant to keep the airway patent; it may not obstruct the airway.

What are the goals of care when working with families according to the family health system? Select all that apply. To improve family health or well-being To help the family prepare for later transitions To assist in family management of illness conditions To promote positive family behaviors to achieve essential tasks To achieve health outcomes related to the family's areas of concern

To improve family health or well-being To assist in family management of illness conditions To achieve health outcomes related to the family's areas of concern When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse should help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.

Which approach is a comforting approach that communicates concern and support? Touch Listening Knowing the client Providing a positive presence

Touch Touch is a comforting approach that involves reaching out to clients to communicate concern and support. Listening is a critical component of nursing care and is necessary for meaningful interactions with clients. Knowing the client comprises both the nurse's understanding of a specific client and his or her subsequent selection of interventions. Providing presence is a person-to-person encounter that conveys a closeness and sense of caring.

Which intervention reflects the nurse's approach of "family as a context"? Trying to meet the client's comfort Evaluating the client family's coping skills Evaluating the client family's energy level Trying to meet the client family's nutritional needs

Trying to meet the client's comfort In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs.

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy? "No, try to be in your sense of reality." "Yes, today is the day that you just mentioned." "You should try improving your awareness level." "Try to recall your past memories associated with the day."

"Yes, today is the day that you just mentioned." Validation therapy an approach to communication with a confused client with dementia. In this approach, the nurse accepts the description of the time and place as stated by the client. Therefore, the statement "Yes, today is the day that you just mentioned" represents the use of validation therapy. Asking the client to reorient himself or herself to reality and asking him or her to improve his or her awareness level are examples of the reality orientation approach. Reminiscence is an approach that asks the client to recall his or her past experience.

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what? Falls Impaired cognition Imbalanced nutrition Impaired gas exchange

Falls The client is at risk for falls related to the leg prosthesis and history of syncope. There is no evidence or contributing factors in the patient scenario of impaired cognition, imbalanced nutrition, or impaired gas exchange.

Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply. Fatigue Increased libido Morning sickness Breast enlargement Braxton Hicks contractions

Fatigue Morning sickness Breast enlargement Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester of pregnancy. Braxton Hicks contractions are observed during the third trimester of pregnancy.

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament? Highly active Irritable and irregular in habits Negative reaction to new stimuli A positive mild-to-moderately intense mood

Negative reaction to new stimuli A slow-to-warm up child may react negatively with mild intensity to any new stimuli or a change. A difficult child is highly active as well as irritable and irregular in habits. An easy child usually has a positive mild-to-moderately intense mood.

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? All nursing functions will be completed by discharge. All invasive intravenous lines will remain patent. The client will remain awake, alert, and oriented at all times. The client will be free of signs and symptoms of infection by discharge.

The client will be free of signs and symptoms of infection by discharge. Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.

A new mother said to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." What does the nurse infer from this information? The patient is of Asian culture. The patient is of African culture. The patient is of North American culture. The patient is of Latin American culture.

The patient is of North American culture. The people who belong to United States and Western Europe culture possess individualistic characteristics. The people who belong to Asia, Africa, and Latin America do not possess individualistic characteristics; instead, they have a collectivistic approach. The new mother who belongs to any of these cultures other than the North American culture may depend on elder family members for child-rearing.

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

To the client from outside sources Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. "From the client to others," "From the client by using special techniques to destroy infectious fluids and secretions," and "To the client by using special sterilization techniques for linens and personal items" are incorrect concepts related to protective environment isolation.

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months? Holding a pencil Showing hand preference Placing objects into containers Transferring objects from hand to hand

Transferring objects from hand to hand Infants of aged 6 to 8 months may be able to transfer objects from hand to hand. Infants of aged 10 to 12 months may be able to hold a pencil. Infants of aged 8 to 10 months may show a hand preference. Infants of aged 10 to 12 months may be able to place objects into a container.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions? "You do not need to wear them while you are awake, but it is important to wear them at night." "You will need to apply them in the morning before you lower your legs from the bed to the floor." "If they bother you, you can roll them down to your knees while you are resting or sitting down." "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."

"You will need to apply them in the morning before you lower your legs from the bed to the floor." Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

Which critical thinking skill does the nurse associate with the concept of maturity? Eagerness to acquire knowledge Being tolerant of different views Trust in own reasoning processes Ability to reflect on own judgments

Ability to reflect on own judgments Maturity is the ability of a critical thinker to reflect on his or her own judgments. A critical thinker realizes that multiple solutions are acceptable. Inquisitiveness is the eagerness to acquire knowledge. A critical thinker is considered open-minded if he or she respects the right of others to have different opinions and is tolerant of different views. The critical thinker possesses self-confidence and trusts in his or her own reasoning process.

The nurse is measuring the body temperature of four clients in a clinical setting. Which client is in need of rewarming through cardiopulmonary bypass? A B C D

B Hypothermia is classified as mild hypothermia (body temperature of 34 °C to 36 °C/93.2 °F to 96.8 °F), moderate hypothermia (body temperature of 30 °C to 34 °C/86 °F to 93 °F), and severe hypothermia (body temperature below 30 °C/86 °F). Client B, with a body temperature of 85.3 °F, is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 86 °F. Clients A, C, and D do not have a temperature less than 86 °F; therefore, they may not need rewarming through cardiopulmonary bypass.

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? Sodium Calcium Potassium Phosphorus

Calcium The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps to balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium, because they exist in a specific ratio, phosphorus is not related to the development of tetany.

An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client? Clinical nurse specialist (CNS) Certified nurse midwife (CNM) Certified nurse practitioner (CNP) Certified registered nurse anesthetist (CRNA)

Certified nurse midwife (CNM) A certified nurse midwife (CNM) is qualified and has the skills to care for a pregnant woman. A clinical nurse specialist (CNS) is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. A certified nurse practitioner (CNP) is an APRN who provides healthcare to a group of clients, usually in an outpatient, ambulatory care, or community-based setting. A certified registered nurse anesthetist (CRNA) is an APRN with an advanced education in a nurse anesthesia accredited program.

A registered nurse instructs a nursing student to use knowledge and experience to choose proper strategies to use to care for clients. Which critical-thinking skill does the registered nurse refer to? Analysis Evaluation Explanation Interpretation

Explanation The critical-thinking skill of explanation involves using knowledge and experience to provide client care. The nursing practice of assessing whether the obtained data is true is called analysis. Using criteria such as expected outcomes, pain characteristics, and learning objectives to determine results of nursing actions is an evaluation skill. The nursing practice of being orderly in data collection and looking for patterns to categorize data refers to interpretation.

What critical thinking skill is applicable when knowledge and experience is used to care for clients? Analysis Evaluation Explanation Interpretation

Explanation When the nurse is using his or her experience to care for clients, the skill called explanation is involved. Analysis is applicable when the information is collected with an open mind. Evaluation is applicable when the information is used to determine nursing actions. Interpretation is involved when orderly data is collected.

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? Focusing Restating Exploring Accepting

Focusing Focusing is a technique that directs a client back to the original topic of discussion. Restating the main idea of what the client has said encourages the client to continue speaking or clarifies what has been said. Exploring permits the nurse to delve deeper into the subject when the client tends to stay on a superficial level. Accepting is a technique used to understand and demonstrate regard for what the client stated.

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what? Picks up the walker and carries it for short distances Uses the walker only when someone else is present Moves the walker no more than 12 inches (30.5 cm) during use States that a walker will be purchased on the way home from the hospital

Moves the walker no more than 12 inches (30.5 cm) during use Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches (30.5 cm) in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? Prevent a client from pulling out an intravenous (IV) when there is concern that the client cannot follow instructions or is confused. Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Maintain immobilization of a client's leg to prevent dislodging a skin graft. Keep an older adult client from falling out of bed following a surgical procedure.

Prevent an adult client from getting up at night when there is insufficient staffing on the unit. Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for this and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.

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

"I should carry objects close to my body." By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? Lactated Ringer solution 5% dextrose and water 0.9% normal saline 0.45% normal saline

0.9% normal saline Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.

What is the most important nursing action involved in caring for a client using medications to manage disease? Administering the medications Teaching about the medications Ensuring adherence to the medication regimen Evaluating the client's ability to self-administer medications

Administering the medications The most important part of the nursing practice regarding medication is administering the medications. Administering medications safely requires an understanding of the legal aspects of healthcare, pharmacology, pathophysiology, human anatomy, and mathematics. Teaching about the medications, ensuring adherence to the medications, and evaluating the client's ability to self-administer medications are responsibilities of the nurse performed before or after the administration of medicines.

During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? Neurasthenia Anorexia nervosa Shenjing shuairuo Ataque de nervios

Anorexia nervosa Anorexia nervosa is a Western culture-bound eating disorder characterized by obsession with body image. A client who continues to follow weight loss diets despite being a healthy weight may be at risk for malnutrition. The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses on a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latino-Caribbean culture-bound syndrome and is not associated with body image.

Which statement is true for attachment in the newborn? Attachment occurs for the first 28 days. Attachment begins in the first week of birth. Attachment is the overlapping of soft skull bones. Attachment is the interaction between parent and child.

Attachment is the interaction between parent and child. Attachment is the interaction between the parent and child. The nurse promotes the parents' and newborn's need for physical contact by encouraging breast feeding. Attachment is a process that evolves over the first 24 months. The newborn is awake and alert for the first half-hour after birth, during which parent-child interaction begins. Molding is the overlapping of the soft skull bones commonly seen in newborns that had vaginal births. Molding allows the fetal head to adjust to the various diameters of the maternal pelvis during birth.

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? Attempt to identify the client's concerns. Reassure the client that the surgery is routine. Report the client's anxiety to the healthcare provider. Provide privacy by pulling the curtain around the client.

Attempt to identify the client's concerns. The nurse should assess the situation before planning an intervention. Reassuring the client that the surgery is routine minimizes concerns and cuts off communication. Reporting the client's anxiety to the healthcare provider is premature; more information is needed. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? Crohn disease Cushing disease End-stage renal disease Gastroesophageal reflux disease

End-stage renal disease One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

Which nursing action would be considered a part of self-regulation in the decision-making process? Reflecting on one's own experiences Looking at all the situations objectively Supporting findings and conclusions Making careful assumptions about a client's information

Reflecting on one's own experiences Self-regulation requires the nurse to reflect on his or her own experiences. Explanation requires looking at all situations objectively. Findings and conclusions are supported by explanation. Analysis requires the nurse to not make any careless assumptions.

Which definition is involved in the caring process called knowing according to Swanson's theory of caring? Being emotionally present for the other Sustaining faith in the other's capacity to get through an event Striving to understand an event as it has meaning in the life of the other Facilitating the other's passage through life transitions and unfamiliar events

Striving to understand an event as it has meaning in the life of the other In Swanson's theory of caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other's capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other's passage through life transitions and unfamiliar events is related to the caring process called enabling.

How should the nurse prevent footdrop in a client with a leg cast? Encourage complete bed rest to promote healing of the foot. Place the foot in traction. Support the foot with 90 degrees of flexion. Place an elastic stocking on the foot to provide support.

Support the foot with 90 degrees of flexion. To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.

Which assessment finding is associated with depression? The client has islands of intact memory. The client has impaired recent and remote memory. The client has impaired recent and immediate memory. The client needs step-by-step instructions for simple tasks.

The client has islands of intact memory. Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

Why does the nurse establish "moderately hard" client-centered goals? Select all that apply. To decrease the cost of treatment during therapy To decrease the number of follow-up visits by the client To achieve the goal in a shorter period of time with less effort To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal

To prevent the client from quitting before the goal is achieved To prevent the client from losing motivation toward achieving the goal Healthcare providers generally design moderately hard client-centered goals because, if the goals are too hard to achieve, the client may give up before completely achieving them. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursuing. Designing moderately hard client-centered goals will not decrease the cost of the treatment. Moderately hard client-centered goals will not necessarily be completed in a shorter period of time with less effort. Establishing moderately hard client-centered goals will not necessarily reduce the number of follow-up visits required.

Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply. Using pincer grasp well Picking up small objects Showing hand preference Crawling on hands and knees Pulling oneself to standing or sitting

Using pincer grasp well Picking up small objects Showing hand preference The fine-motor skills evident in 8 to 10 month-old infants include the accurate use of the pincer grasp. It also involves picking up small objects. At this stage, the infants may also demonstrate a hand preference. Crawling on hands and knees and pulling oneself to standing or sitting position are considered gross motor skills.

Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? Listening Spiritual caring Providing presence Relieving pain and suffering

Relieving pain and suffering Relieving pain and suffering is not just about giving medications but providing comfort, dignity, respect, and peace to a client. Listening helps to obtain meaningful interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps to convey closeness and a sense of caring.

The home healthcare nurse visits a client who lives with her two grandchildren. The client's daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form? Nuclear family Extended family Single-parent family Skip-generation family

Skip-generation family A skip-generation family form is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of a husband and wife and one or more children. An extended family consists of the nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, or desertion. It may also occur when a single person decides to have or adopt a child.

A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what? Potassium Sodium bicarbonate Carbon dioxide Sodium chloride

Sodium bicarbonate Sodium bicarbonate is a base and one of the major buffers in the body. Potassium, a cation, is not a buffer; only a base can buffer an acid. Carbon dioxide is carried in aqueous solution as carbonic acid (H 2CO 3); an acid does not buffer another acid. Sodium chloride is not a buffer; it is a salt.

An adolescent who had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? "I can ride my bike in about a week." "I don't have to go to gym class for 3 months." "I can't perform any weightlifting for at least 6 weeks." "I can never participate in football again."

"I can't perform any weightlifting for at least 6 weeks." Weightlifting puts a strain on the incision and should be avoided for at least 6 weeks. Activities such as bike riding and physical education classes and football are contraindicated for approximately 3 weeks after uncomplicated surgery for an inguinal hernia. Refraining from these activities for this period of time prevents stress on the incision and promotes healing. However, the client should not participate in any of these activities until cleared by the surgeon.

The registered nurse is teaching a nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? "I should serve food that is easy to eat." "I should assist the client with eating." "I should monitor weight and food intake once in a month." "I should offer food supplements that are tasty and easy to swallow."

"I should monitor weight and food intake once in a month." The nurse should monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse should serve food that is easy to eat provide assistance with eating. The nurse should also offer food supplements that are tasty and easy to swallow.

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? "I would, but my back hurts today." "Okay. It will be my good deed for the day." "Of course. I want to do whatever I can for you." "I would like to, but it is not in my job description."

"Of course. I want to do whatever I can for you." Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse's job description.

An 80-year-old client is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated, because she is alert and able to care for herself. The nurse's best response is: "The body's fluid needs decrease with age because of tissue changes." "Access to fluid may be insufficient to meet the daily needs of the older adult." "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

"The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased." For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake.

A newly hired nurse during orientation is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? "Let me get my preceptor." "Wash your hands before and after any client care." "Clean all instruments and work surfaces with an approved disinfectant." "Ensure proper disposal of all items contaminated with blood or body fluids."

"Wash your hands before and after any client care." The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of hand washing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse? "You must keep up a strong appearance for him." "I think he'd have difficulty dealing with that now." "Don't you think he knows that without you telling him?" "You should share your feelings with him while you can."

"You should share your feelings with him while you can." It is difficult to work through a loss; however, encouraging the sharing of feelings helps both parties feel better about having to let go. The response, "You must keep up a strong appearance for him," impedes the work of acceptance of one's finality and the use of the remaining time to the best advantage. There is no evidence to suggest that the client cannot cope with these emotions; the response, "I think he'd have difficulty dealing with that now," denies that this is a time for closeness and honesty. The response, "Don't you think he knows that without you telling him?" is demeaning, closes off communication, and does not foster the expression of feelings.

On the third postoperative day after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? Explain why there is a need to increase activity. Emphasize that with a prosthesis, there will be a return to the previous lifestyle. Appear cheerful and noncritical regardless of the client's response to attempts at intervention. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving. The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? Attention span Primary language Coping mechanisms Activity and coordination

Attention span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to? Blended family Extended family Alternative family Single-parent family

Blended family The child belongs to a blended family. Such a family is formed when parents bring unrelated children from prior relationships into a new, joint living situation. Extended family comprises the husband, wife, children, uncles, aunts, cousins, and grandparents. An alternative family may have grandparents caring for grandchildren. It may also be a multi-adult household with cohabiting partners or homosexual couples. A single-parent family is formed when one parent cares for the children following the death, divorce, or desertion of the other parent. A single person may also decide to have or adopt a child.

Which activity would the nurse use as an example of fine motor skills of infants aged 2 to 4 months? Turning from side to back Sitting erect using support Showing good head control Bringing objects from hand to mouth

Bringing objects from hand to mouth Bringing objects from hand to mouth indicates a fine motor skill observed in infants aged 2 to 4 months. Turning from side to back, sitting erect using support, and showing good head control are gross-motor skills.

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? Care that supports physical functioning Care that supports homeostatic regulation Care that supports psychosocial functioning Care that provides immediate short-term help in physiological crises

Care that supports homeostatic regulation Providing perioperative care (care before, during, and immediately after surgery) involves care that supports homeostatic regulation. If interventions are provided to support the client in doing daily activities, they are considered a physiological basic domain that supports physical functioning. Providing behavioral and cognitive therapies helps to support psychosocial functioning and facilitates lifestyle changes. Providing immediate short-term help in physiological crises helps to support protection against harm.

The nurse is helping a client and his or her family to set and meet goals with minimal financial cost, time, and energy. Which professional role of the nurse is applicable in this situation? Educator Advocate Manager Caregiver

Caregiver As a caregiver, the nurse helps the client and his or her family set goals. The nurse also assists them in meeting these goals with a minimal financial cost, time, and energy. The educator role is used to explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or client behavior, and evaluate the client's progress in learning. The advocator role helps protect the client's human and legal rights and provide assistance in asserting these rights if the need arises. In the manager role, the nurse coordinates the activities of members of the nursing staff and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency.

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply. Check tubing for kinks Run wires under carpeting Post "no smoking" signs in the clients' rooms Place oxygen tanks flat in the carts when not in use Make sure that the client is familiar with the phrase "Stop, drop, and roll"

Check tubing for kinks Post "no smoking" signs in the clients' rooms Oxygen tubing should be checked for kinks during oxygen use. "No smoking" signs should be posted in the clients' rooms. Wires should not be kept under carpeting because heat buildup or friction can cause a fire. Oxygen tanks should be placed in an upright position in their carts or flat on floors. Being familiar with the phrase "Stop, drop, and roll" helps to describe when clothing or skin is burning.

After reviewing a client's reports, the primary healthcare provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? Select all that apply. Peptic ulcer Chronic renal failure Cognitive impairment Congestive heart failure Chronic obstructive lung disease

Chronic renal failure Congestive heart failure Chronic obstructive lung disease Palliative care aims to minimize client suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce client suffering from the beginning of the therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore, these clients do not require palliative care.

How can a nurse best evaluate the effectiveness of communication with a client? Client feedback Medical assessments Health care team conferences Client's physiologic responses

Client feedback Feedback permits the client to ask questions and express feelings and allows the nurse to verify client understanding. Medical assessments do not always include nurse-client relationships. Team conferences are subject to all members' evaluations of a client's status. Nurse-client communication should be evaluated by the client's verbal and behavioral responses.

Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply. Privacy level Emotional status Information exchange Level of caring expressed Growth and development

Emotional status Growth and development Growth and development and emotional status are two psychophysiologic factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? Knowing Enabling Doing for Being with

Enabling The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? Administer the prescribed as needed (PRN) sedative. Encourage the client to express feelings. Explain the postprocedure course of treatment. Reassure the client that there are others with this problem.

Encourage the client to express feelings Communication is important in relieving anxiety and reducing stress. Administering the prescribed PRN sedative does not acknowledge the client's feelings and does not address the source of the anxiety. Learning is limited when anxiety is too high. The focus should be on the client, not others. Reassurance may cut off communication and deny emotions.

A client with chronic renal failure stops responding to the treatment. On examination, the primary healthcare provider determines that the client is terminally ill. What is the best nursing intervention in this situation? Suggest that the family members get a second opinion. Suggest that the family members continue to try different treatments. Encourage the family members to provide pallative care to the client. Inform the family members that the disease is no longer curable and the client will die shortly.

Encourage the family members to provide pallative care to the client. Clients who are terminally ill and no longer respond to treatment are in need of palliative care. Palliative care promotes client comfort and provides important interventions to support the client and family at the end of life. There is no need to get a second opinion from another primary healthcare provider, because the client is terminally ill. Continuing to attempt different treatment until of the death of the client may cause more client suffering. It is not advisable to inform the family members that the client will die soon because it may lead to emotional stress. The palliative care team will help prepare the family for the client's death.

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? Teaching how to make a room allergy-free Referring to a support group for individuals with asthma Arranging with the college to ensure a speedy return to classes Evaluating whether the necessary lifestyle changes are understood

Evaluating whether the necessary lifestyle changes are understood Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what? Hand washing before and after providing client care Cleaning all equipment with an approved disinfectant after use Wearing personal protective equipment (PPE) when providing client care Using medical and surgical aseptic techniques at all times

Hand washing before and after providing client care Hand washing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all these interventions are acceptable procedures and may assist in preventing the spread of infection, none are as effective as hand washing.

Which statement is true about the nursing model "team nursing"? The registered nurse is responsible for all aspects of client care. Client care can be delegated to other healthcare team members. The registered nurse works directly with the client, family members, and healthcare team members. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model "total client care," the registered nurse is responsible for all aspects of client care, care can be delegated from the registered nurse to other healthcare team members, and the registered nurse works directly with the client, family members, and healthcare team members.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? Hypernatremia Hyponatremia Hyperkalemia Hypokalemia

Hyponatremia The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L), and for serum potassium it is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L (145 mmol/L); hyperkalemia results when serum potassium is greater than 5.0 mEq/L (5.0 mmol/L); hypokalemia results when serum potassium is less than 3.5 mEq/L (3.5 mmol/L).

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? Planning Evaluation Assessment Implementation

Implementation The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, social culture.

Which nursing process involves delegation and verbal discussion with the healthcare team? Planning Evaluation Assessment Implementation

Implementation The implementation process involves delegation and verbal discussion with the healthcare team. Planning involves interpersonal or small group healthcare team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and a history of talking with the clients.

Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. Interventions to restore tissue integrity Interventions to optimize neurologic functions Interventions to manage restricted body movements Interventions to promote comfort using psychosocial techniques Interventions to provide care before, during, and immediately after surgery

Interventions to restore tissue integrity Interventions to optimize neurologic functions Interventions to provide care before, during, and immediately after surgery Interventions such as restoring tissue integrity, optimizing neurologic functions, and providing care before, during, and immediately after surgery are classified under physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy[1][2]. Interventions to manage restricted body movements are classified under the simple physiologic domain. Interventions to promote comfort using psychosocial techniques are classified under the behavioral domain.

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer? It shows empathy. It uses distraction. It gives false reassurance. It makes a value judgment.

It gives false reassurance. A person cannot know the results of the biopsy until it is examined under a microscope. The response does not allow the client to voice concerns, shuts off communication, and provides reassurance that may not be accurate. This answer does not empathize with the client; it minimizes the client's concerns. This response is not a form of distraction; it minimizes the client's concern and shuts off communication. This response does not contain any value statements.

A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? Family in later life Family with adolescents Unattached young adult Launching children and moving on

Launching children and moving on The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescents stage of the family lifecycle involves establishing flexible boundaries to accommodate the growing child's independence. An individual experiencing the unattached young adult stage begins to differentiate themselves from his or her family of origin. The young adult establishes him or herself at work while the young adult's parents experience the launching children and moving on stage.

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what? Relieve bronchial spasms Increase depth of respirations Loosen pulmonary secretions Expel carbon dioxide from the lungs

Loosen pulmonary secretions Postural drainage and percussion also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? Private room Semiprivate room Room with windows that can be opened Negative-airflow room

Negative-airflow room Tuberculosis is an airborne contagious disease that is best contained in a negative-airflow room. Negative-airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? Primary Secondary Superinfection Nosocomial

Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

Which concept refers to respecting the rights of others? Maturity Systematicity Inquisitiveness Open-mindedness

Open-mindedness Open-mindedness refers to respecting the rights of others and being tolerant of different viewpoints. Maturity refers to reflecting on one's own judgments and having cognitive maturity. Systematicity refers to being organized and focused. Inquisitiveness refers to acquiring knowledge.

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents? Colitis Stomatitis Paralytic ileus Gastrocolic reflux

Paralytic ileus After abdominal or pelvic surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? Suddenness of the change Obviousness of the change Extent of the change Perception of the change

Perception of the change It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly? Fairness Humility Discipline Perseverance

Perseverance Perseverance requires the nurse to be cautious of an easy answer. If the nurse clarifies some information after talking to the client directly, he or she demonstrates perseverance. Fairness requires the nurse to listen to both the sides in any discussion. Humility is associated with recognizing the need for more information for making a decision. When the nurse is thoroughly aware of what is required and manages his or her time effectively, he or she uses discipline.

A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? Place a surgical mask on the client. Other than standard precautions, no additional precautions are needed. Minimize close physical contact. Cover the client's legs with a blanket.

Place a surgical mask on the client. Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.

Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? Instruct the client to position one arm on each shoulder of the nurses. Direct the client to extend the legs and remain still during the procedure. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.

Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler? Sensorimotor Preoperational Formal operations Concrete operations

Preoperational The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed form birth to 2 years. During this stage, the child learns about himself and his environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifies that the child is able to perform mental operations.

What interventions should the nurse perform while caring for an actively dying client? Select all that apply. Admit the client in hospice care. Perform aggressive laboratory tests. Provide client and family reassurance. Keep the client undisturbed for long time. Perform symptom management in the client.

Provide client and family reassurance. Perform symptom management in the client. The nurse should provide comfort care in an actively dying client. In comfort care, the nurse should reassure the client and family to reduce their emotional anxiety. The nurse should perform symptom management to improve the client's quality of life. The client should not be admitted into hospice care if he or she is actively dying. A client is admitted to hospice care if death is expected within 6 months. The client may not require aggressive laboratory tests when death is imminent. He or she should be repositioned as needed for comfort.

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client? Encouraging frequent naps Strengthening the concept of ageism Reinforcing the client's strengths and promoting reminiscing Teaching the client to increase calories and focusing on a high-carbohydrate diet

Reinforcing the client's strengths and promoting reminiscing Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

Which component of decision-making refers to the duties and activities an individual is employed to perform? Authority Autonomy Responsibility Accountability

Responsibility Responsibility refers to all duties and activities an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? Sharing hope Sharing humor Sharing empathy Sharing observations

Sharing humor Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses should recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client to communicate without the need for extensive questioning, focusing, or clarification.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? Sit down quietly next to the bed and allow her to cry. Pull the curtain and leave the room to provide privacy for the client. Explain to the client that her feelings are expected and they will pass with time. Observe the length of time the client cries and document her difficulty accepting her impending death.

Sit down quietly next to the bed and allow her to cry. Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion without enough information.

Which developmental changes should be evaluated in girls around 12 years of age? Motor skills Visual acuity Skeletal growth Hormonal changes

Skeletal growth Girls around the age of 12 years of age may develop scoliosis (a lateral curvature of the spine); therefore, skeletal growth should be evaluated. Motor skills should be evaluated in preschool children. Visual acuity should be evaluated in school-age children. Hormonal changes should be evaluated in adolescents.

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? Sodium Potassium Chloride Calcium

Sodium Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.

A community healthcare nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness? The children are under-immunized and at a risk for childhood illnesses. The children are more likely to drop out of school and become unemployable. The children have access to healthcare only through the emergency department. The children do not have a physical shelter and may sleep outdoors or in vehicles.

The children do not have a physical shelter and may sleep outdoors or in vehicles Public health organizations use the term absolute homelessness to describe people who have no physical shelter. These children sleep outdoors, in vehicles, abandoned buildings, or other places not intended for human habitation. Relative homelessness describes those who have a physical shelter but one that does not meet the standards of health and safety. Children from both sections of the community tend to be under-immunized and are at risk for childhood illnesses. Both types of homeless children are unable to meet residency requirements for public schools and are more likely to drop out of school and be rendered unemployable. A lack of finances leads both types of homeless children to seek healthcare only in emergency conditions.

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction? The nurse records the vital signs and leaves the room. The nurse adjusts the bed and asks if the client is comfortable. The nurse leaves the door of the room open while attending to the client. The nurse tells the client that the primary healthcare provider will visit soon.

The nurse adjusts the bed and asks if the client is comfortable. The nurse expresses concern and commitment by adjusting the bed and asking if the client is comfortable. This intervention shows the nurse's willingness to enter into a nurse-client relationship and promotes greater client satisfaction. The client may feel that the nurse is just performing a set of assigned tasks by recording the vital signs and leaving the room. This intervention does not build client satisfaction. The nurse should close the door after entering the room to ensure privacy while providing care. The nurse does not provide effective client satisfaction by informing the client about the primary healthcare provider's imminent visit.

A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? Tubing injection port Distal end of the tubing Urinary drainage bag Catheter insertion site

Tubing injection port The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.