Management of Care

Which client should the nurse assess first? A. a client being treated for chronic stable angina who reports a recent increase in chest pain frequency B. a client with chronic hypertension whose blood pressure today is 182/98 mm Hg C. a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week D. a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL

A. a client being treated for chronic stable angina who reports a recent increase in chest pain frequency

Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when the nurse reflects on the decision-making process and the role it will play in making future decisions? A. evaluating B. planning C. implementing D. diagnosing

A. evaluating

A client with stage 1 Alzheimer's disease is diagnosed with terminal lung cancer. The client wonders about "reaching the end" asks the nurse what to do. How should the nurse respond? A. "You need to discuss this issue with your family; they will help you decide what to do." B. "Have you considered putting together a living trust that states your desires?" C. "An advance directive will help to make sure that your wishes are carried out." D. "An advance directive will allow others to make decisions about your care."

C. "An advance directive will help to make sure that your wishes are carried out."

A nurse has forgotten the computer password and asks to use another nurse's password to log on to the computer. Which response by the coworker demonstrates safe computer usage? A. "I will contact information services for you to reset your password." B. "I will write down my password for you until you can reset your password." C. "I will log into the computer for you until you can reset your password." D. "Would you like me to help you contact information services to reset your password?"

D. "Would you like me to help you contact information services to reset your password?"

A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN? A. 8-year-old child admitted that morning with suspected meningitis B. 10-year-old child who had a tonsillectomy that morning C. 9-year-old child with Legg-Calve'-Perthes disease D. 9-year-old child receiving subcutaneous insulin for diabetes mellitus

D. 9-year-old child receiving subcutaneous insulin for diabetes mellitus

A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first? A. Position woman on her left side, and administer oxygen via face mask. B. Perform vaginal exam to rule out umbilical cord prolapse. C. Notify the health care provider (HCP) immediately, and prepare for emergency caesarean birth. D. Document findings on the woman's medical record, and continue to monitor labor progress.

D. Document findings on the woman's medical record, and continue to monitor labor progress.

After completing a shift, a nurse realizes that documentation on a client was not completed before leaving the unit. Which action by the nurse is most appropriate? A. Call the unit and dictate the entry to another nurse. B. Wait to hear if the nurse manager will offer some advice. C. Call and ask the nurse to leave a blank entry for completion tomorrow. D. Enter the information tomorrow stating it is a late entry.

D. Enter the information tomorrow stating it is a late entry.

Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer? A. male nurse who is also assigned to another client receiving brachytherapy B. female nurse with 10 years' experience who suspects she may be pregnant C. male nurse who has floated to this unit from the operating room D. female nurse with 3 years' experience working in oncology

D. female nurse with 3 years' experience working in oncology

The nurse is working as charge on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention? A. obtaining an anaerobic culture specimen from a superficial burn wound B. teaching a newly admitted burn client about the use of pressure garments C. administering oral tetracycline with milk to a client with cellulitis D. discussing the use of herpes zoster vaccine with a young adult

C. administering oral tetracycline with milk to a client with cellulitis

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes A. ensuring the abbreviations are understandable to clients who may seek access to their health records B. using only abbreviations whose meaning is self-evident to an educated health professional C. using those abbreviations defined in full at another location in the client's chart D. limiting abbreviations to those approved for use by the institution

D. limiting abbreviations to those approved for use by the institution

A nurse is caring for a client with pheochromocytoma. What is the most important intervention by the nurse? A. avoiding analgesia administration B. avoiding parents rooming in because they make the client less dependent on staff C. advising a low-calorie, high-nutrient diet D. promoting an environment free from emotional distress

D. promoting an environment free from emotional distress

The nurse is completing discharge teaching with a client who had a long hospital stay. The client gives the nurse a handmade sweater for the personal nursing care. What is the best response by the nurse? Select all that apply. A. "I appreciate the gift but it not appropriate for me to take a personal gift." B. "My hospital has a policy that does not allow a nurse to accept gifts." C. "Maybe I can meet you for coffee next week." D. "Thank you for recognizing my work, I will enjoy wearing this sweater." E. "I cannot take this gift while I am at work."

A. "I appreciate the gift but it not appropriate for me to take a personal gift." B. "My hospital has a policy that does not allow a nurse to accept gifts."

The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot, followed by an infection. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse? A. "I will take the antibiotics until the redness goes away and my foot feels better." B. "I will be sure to wear shoes to protect my feet when I go out to get the mail." C. "I will eat lots of fruit and vegetables and take vitamin C to help this heal." D. "I will manage my pain by putting this foot up on a pillow when it hurts."

A. "I will take the antibiotics until the redness goes away and my foot feels better."

When coaching a client to improve their health, which strategy is the most effective for the nurse to use to help clients take an active role in their health care? A. Ask clients for their views of their health and health care. B. Provide clients with written instructions. C. Ask clients to complete a questionnaire. D. Ask clients if they have any questions about their health.

A. Ask clients for their views of their health and health care.

A nurse is named as a defendant in a pediatric client case. What are guidelines for the nurse to follow prior to the trial? Select all that apply. A. Be prepared to answer questions about the case during the trial. B. Limit contact with the assigned attorney. C. Discuss the case with the involved physician. D. Add comments during the questioning to build the story. E. Use polite language while answering questions.

A. Be prepared to answer questions about the case during the trial. E. Use polite language while answering questions.

The nurse is caring for a client with a blood pressure of 210/94 mm Hg. The health care provider prescribes enalapril 20 mg b.i.d. Which nursing action is best when instructing on the new medication regimen? A. State the new medication, including name, use, and reason for the new medication. B. Teach the client the name and frequency of the new medication. C. Inform the client about the new medication and provide a handout on the use. D. Use the package insert for medication instruction.

A. State the new medication, including name, use, and reason for the new medication.

The nurse is called to serve as a fact witness in the court of law. Which qualifications support the nurse fact witness role? Select all that apply. A. clinical documentation of the incident B. firsthand knowledge of the situation C. advanced nursing degree D. solid educational background E. strong clinical experience

A. clinical documentation of the incident B. firsthand knowledge of the situation

The nurse is preparing for the admission of a client on a stretcher. In what position should the nurse place the bed? A. highest position B. middle position C. high fowlers position D. lowest position

A. highest position

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as A. moxifloxacin 400 mg daily B. moxifloxcin 400 mg qd C. moxifloxacin 400 mg Q.D. D. moxifloxacin 400 mg OD

A. moxifloxacin 400 mg daily

A woman employed full-time wants to request a leave of absence to care for her father who is being treated for colon cancer 300 miles (480 km) away. What should the nurse advise the client to do first? A. Find someone to do her work while she is away. B. Make a plan to see how long she can be out of work without financial concerns. C. Contact her employee resources department about policies guiding leaves of absence. D. Ask her father if he can afford a caregiver.

C. Contact her employee resources department about policies guiding leaves of absence.

In explaining an invasive diagnostic procedure to a client with English as a second language, the nurse recognizes that the client would be best educated if an interpreter was available. What is the best response by the nurse when a family member offers to serve as the interpreter? A. Ask if the client is agreeable with having the family member interpret the information. B. Address with the client that there is a video that can be used to explain the procedure. C. Explain to the client and family member that there are medical interpreters available. D. Inquire when an elder family member present can give permission for an interpreter.

C. Explain to the client and family member that there are medical interpreters available.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention? A. Decrease the anxiety and reduce the workload on the heart. B. Monitor and manage potential complications. C. Reduce the nausea and vomiting and stabilize the blood glucose. D. Control the pain and support breathing and oxygenation.

D. Control the pain and support breathing and oxygenation.

The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first? A. a client with no prenatal care, occasional contractions, BP 148/90 mm Hg, and swollen feet B. a primipara in active labor at 5 cm asking to be admitted and wanting an epidural C. a primipara who is 100% effaced, 8 cm dilated, + 2 station with nausea D. a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid

D. a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid

When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, the nurse realizes the client doesn't fully understand the surgery. The nurse approaches the physician, who curtly says, "I've told this client all about it. Just get the consent." The nurse should A. ask the charge nurse to talk with the physician. B. tell the physician "You didn't give the client enough information." C. explain the procedure more fully to the client and obtain the client's signature. D. tell the physician the client isn't comfortable consenting to surgery at this point.

D. tell the physician the client isn't comfortable consenting to surgery at this point.

When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands: A. although uncomfortable, this reaction isn't serious. B. results of treatment are rapid and dramatic but may not last. C. the client shouldn't buy drugs on the street. D. the client must take benztropine as ordered to prevent a return of symptoms.

D. the client must take benztropine as ordered to prevent a return of symptoms.

A hospitalized 5-year-old child cries daily, is fearful and apprehensive about health care procedures, and does not want to cooperate with the nurse. What is the nurse's best action? A. Ignore the situation because the client will adjust and behavior will improve with time. B. Offer verbal education and client/family teaching on coping skills. C. Refer the family to outpatient counseling following this hospitalization. D. Place an order for a mental health consult for the pediatric client.

B. Offer verbal education and client/family teaching on coping skills.

A woman is brought to the emergency department by her husband, who reports that she accidentally fell down basement stairs and broke her arm. The client is quiet, withdrawn, and not making eye contact. During the examination, inspection reveals numerous bruises at different stages of healing over the client's legs, arms, and abdomen. Which nursing response(s) would be most appropriate to gather additional information? Select all that apply. A. "I've noticed several bruises on your body. Can you tell me how they happened?" B. "I am a mandated reporter of any abuse. Do you understand that I have to report my suspicions?" C. "Do you wish to tell me anything more about how you fell down the stairs?" D. "Your husband has no right to do this to you. Do you want me to call the police?" E. "You have bruises all over your body. Your husband is really beating you, isn't he?"

A. "I've noticed several bruises on your body. Can you tell me how they happened?" B. "I am a mandated reporter of any abuse. Do you understand that I have to report my suspicions?" C. "Do you wish to tell me anything more about how you fell down the stairs?"

A nurse is working in a clinic where a family member's spouse is treated for a sexually transmitted disease. The nurse is concerned about the risk to family members. What is the most appropriate action for the nurse to take? A. Encourage the client to speak with the family member about the diagnosis if the client has not already done so. B. Anonymously inform the family member of the spouse's diagnosis so that they may seek necessary treatment. C. As legally required, inform the family member of the client's diagnosis. D. Provide the local Board of Health with the family member's name so they can contact them with information about the client's diagnosis.

A. Encourage the client to speak with the family member about the diagnosis if the client has not already done so.

A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained? A. "A wire from the generator will be attached to my heart." B. "I wonder if there is any other way to prevent these bad rhythms." C. "The physician will make a small incision in my chest wall and place the generator there." D. "This implanted defibrillator will protect me against some of those bad rhythms my heart goes into."

B. "I wonder if there is any other way to prevent these bad rhythms."

The client with acute mania has been admitted to the inpatient unit voluntarily. The nurse approaches the client with medication to be taken orally as prescribed by the health care provider. The client states, "I don't need that stuff." Which response by the nurse is best? A. "You can't refuse to take this medication." B. "The medication will help you feel calmer." C. "If you don't take it orally, I'll give you a shot." D. "I'll get you some written information about the medication."

B. "The medication will help you feel calmer."

The health care provider is in a client's room doing an assessment. The health care provider walks out of the room and says to the nurse, "I have prescribed furosemide 40 mg orally twice daily for 5 days. Enter the prescription into the computerized order entry system for me." What is the best response by the nurse? A. "I will get the furosemide from the floor stock right now and give it to the client." B. "I will put the order in the computer order entry system and give the furosemide once it arrives from the pharmacy." C. "I will find you a computer that is not being used so you can enter the order into the computerized order entry system." D. "I will need to let the charge nurse know about the order so it can be entered in the computerized order entry system." E. will call the pharmacy and have them send the furosemide right away."

C. "I will find you a computer that is not being used so you can enter the order into the computerized order entry system."

During the planning step of the nursing process, the nurse A. writes a statement about the client's health problem. B. determines the client's goal achievement. C. establishes short- and long-term goals. D. gathers objective data.

C. establishes short- and long-term goals.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? A. positioning the client on the side with the knees flexed B. encouraging frequent visits from family and friends C. administering frequent oral feedings D. administering an analgesic once per shift, as ordered, to prevent drug addiction

A. positioning the client on the side with the knees flexed

The nurse is assigned a client newly diagnosed with type 2 diabetes. Which tasks should the nurse delegate to a unlicensed assistive personnel (UAP)? A. teaching the client how to use a glucometer B. reminding the client to check the glucose level before each meal C. assessing the client's technique when injecting insulin D. making an appointment with the dietitian

B. reminding the client to check the glucose level before each meal

In which situation can a client's confidentiality be breached legally? A. to answer a request from a client's spouse about the client's medication B. when a client near discharge is threatening to harm an ex-partner C. in a student nurse's clinical paper about a client D. when a client's employer requests the client's diagnosis to initiate medical claims

B. when a client near discharge is threatening to harm an ex-partner

A client is being discharged with a prescription for enoxaparin. What will the nurse document to address that medication teaching occurred? Select all that apply. A. the client's response to teaching B. the client's knowledge of adverse effects such as bleeding, bloody or black stools. C. the client's knowledge of the time for the next dose D. he client's ability to pay for the medication E. the client's ability to select a site for injection

A. the client's response to teaching B. the client's knowledge of adverse effects such as bleeding, bloody or black stools. C. the client's knowledge of the time for the next dose E. the client's ability to select a site for injection

While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity? We were in labor together." Which response by the nurse would be most appropriate? A. Tell the client "I need to ask the woman's permission before discussing her well-being." B. Explain to the client that "nurses are not allowed to discuss other clients on the unit." C. Ignore the client's question and continue with morning care. D. Tell the client "I'm not sure how the other woman is doing today."

B. Explain to the client that "nurses are not allowed to discuss other clients on the unit."

Reusable blood pressure cuffs and single-use disposable blood pressure cuffs are both available for use in the emergency department. In order to conserve resources, for which client would a clean, reusable blood pressure cuff be appropriate? A. a 30-year-old client who was in a motor vehicle collision and has multiple open bleeding wounds B. an 87-year-old female client in the emergency department for chest pain C. an 8-year-old male client diagnosed with pertussis D. a 47-year-old client with an abscess and diagnosed with MRSA to previous abscesses

B. an 87-year-old female client in the emergency department for chest pain

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request which prescription? A. a lactation consultation B. an x-ray for gastric tube placement C. a serum blood glucose level D. an arterial blood gas

B. an x-ray for gastric tube placement

An agitated client demands to see the chart to read what has been written about the client. Which statement is the nurse's best response to the client? A. "You may see your chart after you're discharged." B. "I'm sorry. The chart is the property of the facility. We don't permit clients to read their charts." C. "You have the right to see your chart. Please discuss your wish with your physician." D. "Please discuss this matter with your attorney."

C. "You have the right to see your chart. Please discuss your wish with your physician."

During a meeting with nurse managers from the crisis intake unit, acute mental health unit, and mental health long-term care unit, the hospital risk manager says, "Approximately 57% of our client safety problems can be directly attributed to poor handoffs." What solution might the nurse managers implement to improve these statistics? A. Nursing staff should complete a checklist to take more care in interpreting primary health care provider prescriptions. B. One nurse per shift should be responsible for receiving all medications that are delivered from pharmacy. C. Initiate a template of transfer information to be communicated when a client is transferred from one care setting to another. D. Nursing staff should complete and document admission history and physicals within one hour of arrival on a unit.

C. Initiate a template of transfer information to be communicated when a client is transferred from one care setting to another.

A 16-year-old client requires chemotherapy for leukemia. The client's parents support the health care provider's recommendation, but the client is refusing treatment. What is the nurse's best initial action? A. Give advice to the client's parents on the best method of convincing the client to take the treatment. B. Inform the client that if the parents agree with the treatment plan, their consent will be honored. C. Request that the health care provider thoroughly explain the benefits and consequences of treatment to the client. D. Advise the client to take the treatment because the health care provider knows best.

C. Request that the health care provider thoroughly explain the benefits and consequences of treatment to the client.

A hospitalized client fell on the floor and sustained a small laceration on the hand that requires stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit in order to suture the laceration. Which issue should be resolved before proceeding with suturing? A. the cosmetic effect from not having a plastic surgeon do the suturing. B. the intern's ability to suture. C. bupivacaine with epinephrine used as the local anesthetic. D. the client's room as an aseptic environment.

C. bupivacaine with epinephrine used as the local anesthetic.

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should A. ask the spiritual counselor to summarize the visit in the client's medical record. B. ensure that the the hospital administration approves the counselor. C. ask to be present during the visit to explain any medical information or answer questions about the client's care. D. take measures to ensure privacy during the counselor's visit.

D. take measures to ensure privacy during the counselor's visit.

A 17-year-old unmarried primigravida client at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do first? A. Refer the client to a social worker for enrollment in a food assistance program. B. Instruct the client in methods for low-cost, highly nutritious meal preparation. C. Ask the client if she has a job and the amount of income earned. D. Determine whether the client qualifies for local assistance programs.

A. Refer the client to a social worker for enrollment in a food assistance program.

A nurse is caring for an 8-year-old female with multiple, chronic urinary tract infections. While the nurse helps the child's parent provide morning care, the child states, "My uncle doesn't clean me that way." The parent becomes visibly upset and gives the girl a stern warning not to discuss the matter. What is the priority action for the nurse? A. Document a note on the child's chart about the event. B. Notify the nursing supervisor and the authorities of the possibility of abuse. C. Do nothing, but continue to observe interactions. D. Ask the mother for more information about the uncle who is cleaning the child.

B. Notify the nursing supervisor and the authorities of the possibility of abuse.

A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section? A. admitting nurse B. physician C. senior staff nurse D. the nurse assigned to the client

B. physician

What information must a medication order include? A. drug class B. physician's signature C. client allergies D. possible adverse reactions

B. physician's signature

The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns? A. "It's understandable to feel that way. But clients with end-stage AIDS who have advanced directives generally experience a less painful death that those individuals who don't." B. "Many people first feel that way when they are admitted into hospice. Although the focus of your care has changed from curative to supportive, your physician will still continue directing it." C. "Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so the physician will be able to provide it if you can't tell him yourself." D. "You don't need to feel that way. Your physician is required by law to sign your orders and the hospice nurses will be contacting him with updates on your condition."

C. "Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so the physician will be able to provide it if you can't tell him yourself."

There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital? A. a 10-year-old with a simple fracture of the femur, who is crying and cannot find his parents B. an older adult with severe headache, but conscious C. a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious D. middle-aged male with severe asthma, heart rate of 120 bpm, and is having difficulty breathing

C. a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious

A clinic nurse is assigned to care for a suicidal client. During the preinteraction phase, what should the nurse's priority be? A. discussing the future with the client B. assessing the client's home environment and relationships outside the hospital C. exploring the nurse's own feelings about suicide D. referring the client to a member of the clergy to discuss the moral implications of suicide

C. exploring the nurse's own feelings about suicide

The nursing staff on the antepartal unit has leuprolide acetate and medroxyprogesterone acetate in the pharmacy for their clients. The nursing staff observed that the vials are similar in size and shape and could be confused. In order to promote client safety, the nursing staff should take which actions? Select all that apply. A. Leave repositioning of drugs to pharmacy staff to resolve. B. Collaborate with pharmacy staff to develop a location that works well for both groups. C. Petition the pharmacy to relocate one drug away from the other product. D. Communicate concerns, measures to remediate, and final decisions to all staff. E. Move the drugs to a new position within the medication administration system during the night shift.

B. Collaborate with pharmacy staff to develop a location that works well for both groups. C. Petition the pharmacy to relocate one drug away from the other product. D. Communicate concerns, measures to remediate, and final decisions to all staff.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? A. Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. B. Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. C. Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. D. Review and revise the way client education is conducted in the surgeons' office.

C. Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.