NRSG 200 practice exam

The nurse asks the client, "What do you fear most about your surgery tomorrow?" This is an example of which communication technique? 1. Providing general leads 2. Seeking clarification 3. Presenting reality 4. Summarizing

1 1. Rationale: It encourages the client to verbalize and choose the topic of the conversation. Option 2 is used when the nurse is unsure of the message and asks the client to repeat or restate the message. Option 3 is used to help a client differentiate the real from the unreal, and there is no information available to indicate this is a concern in this situation. Option 4 is used at the end of an interview or teaching session

Which one of the following might be the BEST way to measure adherence to a prescribed medication regime? 1. Direct observation of medication administration 2. Evidence of illness complications or exacerbations 3. Monitoring laboratory values of elements influenced by the medication 4. Questioning the client about his or her medication routine

1 Although not always practical, direct observation is the best method to measure adherence (for example, watching heroin addicts actually take their methadone dose). Because lack of adherence may be life threatening or damaging to the client as well as others, waiting until the client displays illness and waiting until laboratory values reflect a lack of adherence are not the best methods (options 2 and 3). Client report or recall is not always accurate, even if the client believes he or she is telling the truth (option 4)

If unable to locate the client's popliteal pulse during a routine examination, what should the nurse do next? 1. Check for a pedal pulse. 2. Check for a femoral pulse. 3. Take the client's blood pressure on that thigh. 4. Ask another nurse to try to locate the pulse.

1 If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point (option 2). Taking a thigh BP requires locating the popliteal pulse (option 3). Because the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate (option 4).

Which is the most effective nursing action for preventing and controlling the spread of infection? 1. Thorough hand hygiene 2. Wearing gloves and masks when providing direct client care 3. Implementing appropriate isolation precautions 4. Administering broad-spectrum prophylactic antibiotics

1 Rationale: Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission. Regular and routine hand hygiene is the most effective way to prevent movement of potentially infective materials. PPE (gloves and masks) is indicated for situations requiring standard precautions (option 2). Isolation precautions are used for clients with known communicable diseases (option 3). Routine use of antibiotics is not effective and can be harmful due to the incidence of superinfection and development of resistant organisms (option

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? 1. Goggles 2. Gown 3. Surgical mask 4. Clean gloves

1 1. Rationale: Unless overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off, goggles may be worn repeatedly (option 1). Since gowns are at high risk for contamination, they should be used only once and then discarded or washed (option 2). Surgical masks (option 3) and gloves (option 4) are never washed or reused.

The nurse is teaching a client about wound care during a followup visit in the client's home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence based practice when the client states, "I just don't know how I can afford these dressings"? 1. Integrity 2. Intellectual humility 3. Confidence 4. Independence

1 By reconsidering the type of dressing used based on research, the nurse is using integrity. Options 2 and 3 are critical thinking attitudes characterized by an awareness of the limits of one's own knowledge, and being trustworthy. Option 4 indicates an attitude of not being easily swayed by the opinions of others

The client is complaining of shortness of breath. His respirations are 28 and labored. The bed is currently in the flat position. The nurse puts the bed in which position? 1. Fowler's 2. Semi-Fowler's 3. Trendelenburg 4. Reverse Trendelenburg

1 Rationale: Fowler's is a semisitting position that should ease the client's breathing. The head of the bed (HOB) in semi-Fowler's is lower (option 2). The HOB is lowered in the Trendelenburg position (option 3). Although the HOB is raised in the reverse Trendelenburg

Because a client recently diagnosed with diabetes mellitus is confident that blood sugar control can be improved with diet and exercise alone, and recently checked out a video on the management of diabetes at the HMO education center, the client's actions are most representative of which model? 1. Health belief model 2. Clinical model 3. Role performance model 4. Agent-host-environment model

1 Rationale: The behavior is most representative of health promotion, which is the central focus of the health belief model. The clinical model focuses on relieving signs and symptoms of illness (option 2). The role performance model emphasizes social activities such as fulfilling a particular role (option 3). The agent-host- environment model focuses on predicting illness (option 4).

The nurse who uses appropriate therapeutic listening skills will display which behaviors? Select all that apply. 1. Absorb both the content and the feeling the client is conveying. 2. Presume an understanding of the client needs. 3. Adopt an open professional posture. 4. React quickly to the message. 5. Reassure the client that everything will be fine.

1 and 3 Rationale: Options 1 and 3 are listening behaviors; options 2, 4, and 5 are barriers to listening.

A married mother of three small children has frequent immobilizing headaches of unknown cause. The nurse anticipates that the woman may have which of the following possible reactions? Select all that apply. 1. She feels guilty when unable to perform her usual activities. 2. She is angry and acting out. 3. She shifts some responsibilities to the spouse. 4. She takes on a job to help pay for the medical expenses. 5. She has fewer social interactions with her friends

1, 2, 3 and 5 Rationale: In the sick role, she would likely feel guilt and some anger but give up usual roles and accept help from others, and decrease social interactions. The only reaction that would be unlikely is that the woman would take on a job to pay expenses. This would be inconsistent with the sick role.

The nurse is discussing strategies with the unlicensed assistive personnel (UAP) for bathing a client with dementia. Which strategies would be appropriate for the client? Select all that apply. 1. Cover the client as much as possible. '' 2. Sing or talk to the client. 3. Complete the bath as quickly as possible. 4. Be organized. 5. Expect the client to protest—finish quickly

1, 2, 4 Rationale: Moving quickly may agitate the client (option 3). Protesting, screaming, and crying are not normal. Stop the bath and approach again later (option 5)

Which of the following defense mechanisms for coping with stress could be effective and constructive? Select all that apply. 1. Compensation 2. Displacement 3. Minimization 4. Repression 5. Regression

1, 2, and 4 Rationale: Compensation (option 1) may allow the client to overcome a weakness. Displacement (option 2) allows the client to express feelings safely. Repression (option 4) protects the Information on issues

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. 1. Document the behavior(s) that require continued use of the restraints. 2. Ensure that the restraints are tied to the side rails. 3. Provide range-of-motion exercises when the restraints are removed. 4. Orient the client. 5. Assess the tightness of the restraints.

1, 3, 4, 5 Rationale: Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option 2 is inappropriate because it may cause injury if the side rail is lowered without untying the restraint

The nurse has recently changed jobs to work with young adults and recognizes that sources of stress common to that population include which of the following? Select all that apply. 1. Marriage 2. Aging parents 3. Starting a new job 4. Leaving the parental home 5. Decreased physical abilities 6. Changing body structure

1,3,4 Rationale: Common stressors among young adults include marriage, starting a new job, and leaving the parental home. Stressors from aging parents are more common among middleaged adults (option 2); decreased physical abilities is a stressor in older adults (option 5); and changing body structure serves as a stressor in both children and older adults (option 6

The nurse is planning a presentation on oral health at an intergenerational community center. Which statements will be important to include? Select all that apply. 1. Using a bottle during naps and bedtime can cause dental caries in a toddler. 2. Schedule a visit to the dentist when your child is ready to go to school 3. It is important for parents to supervise a child's brushing of their teeth. 4. Most older adults have dentures and don't need to worry about oral care. 5. Older adults are at risk for periodontal disease.

1,3,5 Rationale: The developmental level warrants supervision. If the bottle is given during naps or bedtime, the solution has continuous contact with the toddler's teeth. The first visit to the dentist should occur between the ages of 2 and 3 (option 2). More than 50% of older adults have their own teeth (option 4).

After auscultating the abdomen, the nurse should report which finding to the primary care provider? 1. Bruit over the aorta 2. Absence of bowel sounds for 60 seconds 3. Continuous bowel sounds over the ileocecal valve 4. A completely irregular pattern of bowel sounds

1. Rationale: A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. For absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes (option 2). Continuous bowel sounds are normally heard over the ileocecal valve following meals (option 3). Bowel sounds are more commonly irregular than they are regular (option 4

A nurse tells a client who is struggling with cancer pain, "It is normal to feel frustrated about the discomfort." Which is most representative of the skills associated with the working phase of the helping relationship? 1. Respect 2. Genuineness 3. Concreteness 4. Confrontation

1. Rationale: Respect is correct because the nurse is validating the client's feeling. It is not genuineness (option 2) because the nurse is giving information versus being genuine. Concreteness (option 3) is giving a specific example. The nurse is not confronting (option 4) but supporting through respect for the client's feelings

When the nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skill is the nurse practicing? 1. Creating environments that support critical thinking 2. Tolerating dissonance and ambiguity 3. Self-assessment 4. Seeking situations where good thinking is practiced

1. 1. Rationale: Nurses must embrace exploration of the perspectives of individuals from different ages, cultures, religions, socioeconomic levels, and family structures to create environments that support critical thinking. Option 2 relates to nurses who should increase their tolerance for ideas that contradict previously held beliefs. Option 3 is conducted when a nurse benefits from a rigorous personal assessment to determine which attitudes he or she already possesses and which need to be cultivated. Option 4 occurs when nurses find it valuable to attend conferences in clinical or educational settings that support open examination of all sides of issues and respect for opposing viewpoints.

Which of the following is the purpose of assessing? 1. Establish a database of client responses to his or her health status. 2. Identify client strengths and problems. 3. Develop an individualized plan of care. 4. Implement care, prevent illness, and promote wellness

1. Rationale: Assessing provides a database of the client's physiological and psychosocial responses to his or her health status. Client strengths and problems (option 2) are identified in the diagnosing phase of the nursing process, a care plan is established (option 3) in the planning phase, and care, prevention, and wellness promotion (option 4) are part of the implementing phase.

Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. Identifying major problems or needs 2. Organizing data in the client's family history 3. Establishing short-term and long-term goals 4. Administering an antibiotic

1. Rationale: Identifying problems/needs is part of a nursing diagnosis. For example, a client with difficulty breathing would have Impaired Gas Exchange related to constricted airways as manifested by shortness of breath (dyspnea) as a nursing diagnosis. Organizing the family history is part of the assessment phase. Establishing goals is part of the planning phase. Administering an antibiotic is part of the implementation phase.

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1. Automobile crashes 2. Drowning and firearms 3. Falls 4. Suicide and homicide

1. Rationale: When educating a group of young to middleaged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use. Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents.

It would be appropriate to delegate the taking of vital signs of which client to unlicensed assistive personnel? 1. A client being prepared for elective facial surgery with a history of stable hypertension 2. A client receiving a blood transfusion with a history of transfusion reactions 3. A client recently started on a new antiarrhythmic agent 4. A client who is admitted frequently with asthma attacks

1. Vital signs measurement may be delegated to UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements. In addition, UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client newly started on antiarrhythmic medication (option 3).

Two people have been in a motor vehicle crash and have similar injuries. According to the transaction-based model, their degree of stress from the crash would be 1. Based on previous experience and personal characteristics. 2. Extremely similar since they had the same stimulus. 3. The identical physiological alarm reaction. 4. Different depending on their external resources and support levels.

1. . Rationale: In the transaction model, stress is a very personal experience and varies widely among individuals. Option 2 represents the stimulus model, and option 3 represents the response model of stress. In option 4, external resources and support are a factor in determining stress levels but omit the key aspects of internal/personal influences. Cognitive Level: Applying. Client Need: Psychosocial Integrity.

A major characteristic of the nursing process is which of the following? 1. A focus on client needs 2. Its static nature 3. An emphasis on physiology and illness 4. Its exclusive use by and with nurses

1. Rationale: The nursing process focuses on client needs. It is dynamic rather than static (option 2), emphasizes client responses rather than physiology and illness (option 3), and is collaborative rather than used exclusively by nurses (option 4).

The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client's hearing aid? 1. Turn the hearing aid off. 2. Soak the hearing aid in soapy solution to clean it. 3. Turn the volume all the way up. 4. Remove the batteries.

1. Rationale: Turn off the hearing aid. Option 2 is incorrect because an in-the-ear hearing aid is cleaned with a damp cloth. Option 3 is incorrect; make sure the volume is turned all the way down because a too loud volume is distressing. Check that the battery is in the hearing aid; do not remove the batteries (option 4)

A client reports feeling hungry, but does not eat when food is served. Using clinical reasoning skills, the nurse should perform which of the following? 1. Assess why the client is not ingesting the food provided. 2. Continue to leave the food at the bedside until the client is hungry enough to eat. 3. Notify the primary care provider that tube feeding may be indicated soon. 4. Believe the client is not really hungry.

1. The nurse recognizes that many assumptions (beliefs) could interfere with the client eating—such as that the food presented is not culturally appropriate. These assumptions must be clarified with the process of clinical reasoning. Options 2 and 3 reach conclusions not supported by the facts. In option 4, the nurse has made a judgment or has an opinion that may not be accurate. Also, the nurse is acting without assessment. Implementation should be preceded by assessment

A client newly diagnosed with a chronic condition that will significantly change the lifestyle must learn aspects of self-care. The client exhibits severe anxiety: increased blood pressure and pulse, headache, and nervousness. Based on this situation, how would the nurse appropriately plan the teaching? 1. Recognize that the client's ability to learn is severely impaired and teach only the immediate, critical needs and plan to follow up and reinforce this teaching later. 2. Recognize that the client's learning will be adaptive and begin immediately to implement the full teaching and learning plan. 3. Recognize that the client's ability to learn will be slightly impaired and modify the usual teaching strategies to accommodate for this impairment. 4. Recognize that the client cannot learn at this time, that the level of anxiety must first be reduced, and then teaching can be based on this new level of

1. This client is exhibiting severe anxiety and, therefore, learning is impaired but not impossible (see Table 42-2). Therefore, it is most appropriate for the nurse to teach only those things that are critical for the client to learn at this time. The nurse also recognizes that learning may not be retained at this level of anxiety and plans to reinforce the teaching when the client is less anxious

The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. What decision making is the nurse engaging in? 1. The research method 2. The trial-and-error method 3. Intuition 4. The nursing process

1. . Rationale: The research method uses a research studybased approach to problem solving. Trial and error (option 2) and intuition (option 3) would involve unstructured approaches resulting in less predictable results. The nursing process generally uses application of known interventions, previously determined by the scientific (research) process (option 4).

List five aspects of the skin that the nurse assesses during a routine examination.

1. color 2. temperature 3. edema 3. lesions 4. turgor 5. moisture

When auscultating the blood pressure, the nurse hears: From 200 to 180 mmHg: silence; then: a thumping sound continuing down to 150 mmHg: muffled sounds continuing down to 130 mmHg; soft thumping sounds continuing down to 105 mmHg; muffled sounds continuing down to 95 mmHg; then silence. The nurse records the blood pressure as _____________.

180/95

Which of the following is an expected finding during assessment of the older adult? 1. Facial hair that becomes finer and softer 2. Decreased peripheral, color, and night vision 3. Increased sensitivity to odors 4. An irregular respiratory rate and rhythm at rest

2

A client recently diagnosed with a chronic illness asks for help in understanding the term chronic. It would be correct for the nurse to say which of the following? 1. Symptoms are always less severe than with an acute illness. 2. Chronic illnesses are considered incurable. 3. Signs and symptoms of chronic illnesses tend to be stable for many years. 4. Chronic illnesses have no effective treatments.

2 By definition, a chronic illness has no known cure, the person will always have it to some degree. Although acute illnesses may have severe symptoms, many chronic illnesses also have severe symptoms (option 1). Although signs and symptoms of chronic illnesses may never go completely away, they can get better and worse at different times (option 3). Chronic illnesses can be treated, just not cured (option 4)

The client's temperature at 8:00 AM using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure were within normal range, what would the nurse do next? 1. Wait 15 minutes and retake it. 2. Check what the client's temperature was the last time it was taken. 3. Retake it using a different thermometer. 4. Chart the temperature; it is normal.

2 Rationale: Although the temperature is slightly lower than expected for the morning, it would be best to determine the client's previous temperature range next. This may be a normal range for this client. Depending on that finding, the nurse might want to retake it in a few minutes—no need to wait 15 minutes (option 3) or with another thermometer to see if the initial thermometer was functioning properly. Chart after determining that the temperature has been measured properly (option 4).

After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred? 1. "We will use antimicrobial soap and hot water to wash our hands at least three times per day." 2. "We must wash or peel all raw fruits and vegetables before eating." 3. "A wound or sore is not infected unless we see it draining pus." 4. "We should not share toothbrushes but it is OK to share towels and washcloths."

2 Rationale: Raw foods touched by human hands can carry significant infectious organisms and must be washed or peeled. Antimicrobial soap is not indicated for regular use and may lead to resistant organisms. Hand hygiene should occur as needed. Hot water can dry and harm skin, increasing the risk of infection (option 1). Clients should learn all the signs of inflammation and infection (e.g., redness, swelling, pain, heat) and not rely on the presence of pus to indicate this (option 3). People should not share washcloths or towels

Which individual appears to have "taken on" the sick role? 1. A client who is obese states, "I deserve to have a heart attack." 2. A mother is ill and says, "I won't be able to make your lunch today." 3. A man with low back pain misses several physical therapy appointments. 4. An older adult states, "My horoscope says I will be well again."

2 The mother has taken on the sick role by expecting to be excused from her usual role responsibilities. The sick role states that individuals are not answerable for their illness, contrary to the obese client's perspective (option 1). In the sick role, the client tries to get better as opposed to the man who misses his physical therapy appointments (option 3). The older adult is not following the sick role expectation to rely on competent help (option

A middle-aged male client is experiencing job-related stress associated with the fear of being laid off, resulting in his accepting projects that require a great deal of travel. Which of the following would be the most important health promotion strategy for this client? 1. Exercise 2. Sleep 3. Nutrition 4. Time management

2 Rationale: All four areas of health promotion strategies may be important, but for this client sleep is likely to be the most adversely affected by travel in which changing time zones and unfamiliar sleeping quarters are common. It is easier for clients to adapt to modifying exercise (option 1), nutrition (option 3), and time management (option 4) during travel than it is to control sleep. Thus, it becomes the most important area requiring intervention to avoid worsening the existing stress.

A depressed client who has not bathed or dressed in clean clothes today is reading the lunch menu but is unable to make a decision. Which would be the most appropriate nursing diagnosis for this client? 1. Anxiety 2. Powerlessness 3. Chronic Low Self-Esteem 4. Social Isolation

2 Rationale: Because anxiety and low self-esteem precede powerlessness, which results in indecisiveness, it is the most correct answer; nursing management always deals with the client's current display of needs. Options 1 (anxiety) and 3 (low self-esteem) may cause a sense of powerlessness that results in indecisiveness. Option 4: There is no evidence that the client's social interactions are less than adequate.

The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following? 1. Eliminate the reservoir. 2. Block the portal of exit from the reservoir. 3. Block the portal of entry into the host. 4. Decrease the susceptibility of the host.

2 Rationale: Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other individuals. Since the carrier individual is the reservoir and the condition is chronic, it is not possible to eliminate the reservoir (option 1). Blocking the entry into a host (option 3) or decreasing the susceptibility of the host (option 4) will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir.

Which is a normal finding on auscultation of the lungs? 1. Tympany over the right upper lobe 2. Resonance over the left upper lobe 3. Hyperresonance over the left lower lobe 4. Dullness above the left 10th intercostal space

2 Rationale: Resonance is a normal sound over the lung. Tympany would be heard over the stomach (air filled) (option 1), hyperresonance is never a normal finding (option 3), and dullness would be heard below (not above) the 10th intercostal space (option 4).

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates a need for further teaching? 1. "I am going to use a mirror to check my feet." 2. "I enjoy walking barefoot around the house." 3. "I will file my nails." 4. "I will increase the time that I wear new shoes each day."

2 Rationale: The client needs to avoid walking barefoot because that could cause injury that may result in an infection. Also, neurologic impairment is likely as a result of the diabetes, which may result in decreased sensation. The client would be unaware of an injury

A client with diarrhea also has a primary care provider's order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, "The primary care provider does not know the client has diarrhea." What type of statement is this? 1. A fact 2. An inference 3. A judgment 4. An opinion

2 Rationale: The nurse has inferred and concluded something that is beyond the available information (and in this case may not be accurate). The prescription and the diarrhea are facts (option 1). It would be judgment and opinion if the nurse stated that the laxative would make the diarrhea worse and should not be given (options 3 and 4).

The nurse is concerned about a client who begins to breathe very rapidly. Which action by the nurse reflects clinical reasoning? 1. Notify the primary care provider. 2. Obtain vital signs and oxygen saturation. 3. Request a chest x-ray. 4. Call the rapid response team

2 The nurse's intuition is like a sixth sense that allows the nurse to recognize cues and patterns to reach correct conclusions. The nurse appropriately obtains vital signs and an oxygen saturation to assess the client's clinical picture more fully. Option 1 supports appropriate nursing actions, but the client's respiratory status should be assessed first. Usually, a physician must order a chest x-ray (option 2). The rapid response team (option 4) may be needed if the client's condition becomes more critical.

Which of the following elements is best categorized as secondary subjective data? 1. The nurse measures a weight loss of 10 pounds since the last clinic visit. 2. Spouse states the client has lost all appetite. 3. The nurse palpates edema in lower extremities. 4. Client states severe pain when walking up stairs

2 rationale: Primary data come from the client (option 4), whereas secondary data come from any other source (chart, family). Subjective data are covert (reported or an opinion), whereas objective data can be measured or validated (weight—option 1, edema—option 3

After being admitted for emergency surgery, an 80-year-old client has just returned to the room from the PAR (postanesthesia room). Which nursing interventions are most likely to facilitate effective communication with this client? Select all that apply. 1. Ask the client, "Do you know where you are?" 2. Ask the client or support person about visual or learning problems. 3. Inform the client and support person(s) about events likely to occur during the next 2 hours. 4. Provide the client with instructions about discharge. 5. Tell the client, "You will feel better soon."

2 and 3 Rationale: Assessing possible visual or hearing problems allows the nurse to provide appropriate interventions (e.g., inserting hearing aid). Communicating what will be occurring at a stressful time helps the client feel more secure and can reduce anxiety. Option 1 is not the best answer as the client could say yes/no or nod the head and the nurse will not know if the client fully understands. It would be better to ask the client to tell you where he or she is. Option 4 is important to do; however, immediately after surgery is not the best time as the client may be in pain and/or groggy from the anesthesia. Option 5 is false reassurance because the nurse does not know if the client is going to feel better.

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. 1. Place a padded tongue depressor at the head of the bed. 2. Pad the bed with blankets. 3. Inform the client about the importance of wearing a medical identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment.

2 and 5 Rationale: Options 2 and 5 are measures needed to keep the client safe in the event of another seizure. Option 1 is incorrect because the current nursing literature states to not put anything in the client's mouth during a seizure. Options 3 and 4 are more relevant after the cause of the seizure is known. Seizures are not all classified as epilepsy.

The nurse evaluates the chart of a 65-year-old client with no apparent risk factors and concludes that which immunizations are current? Select all that apply. 1. Last tetanus booster was at age 50 2. Receives a flu shot every year 3. Has not received the hepatitis B vaccine 4. Has not received the hepatitis A vaccine 5. Has not received the herpes zoster vaccine

2, 3, 4 Rationale: Flu shots are recommended for all adults over age 50. Only adults at risk need to receive hepatitis B and A vaccine (note that this is different than for children). Options 1 and 5 are incorrect because all adults should receive a tetanus booster every 10 years (or sooner if injured) and adults over age 60 should receive the herpes zoster vaccination.

Because a client with human immunodeficiency virus (HIV) is scheduled to begin several medications to manage the infection, the nurse will need to provide client education. Which client characteristics are most likely to predict adherence with the treatment program? Select all that apply. 1. Educational level 2. A trusting relationship with the health care provider 3. An expectation that the medications will be helpful 4. Being able to take the medications twice daily instead of four times daily 5. Sex

2, 3, 4 Rationale: Significant evidence exists that a trusting relationship with the provider, effectiveness of the medication, and simple dosing regimen are important predictors of adherence to a medical regimen. Neither education nor sex has been shown to be a predictive factor (options 1 and 5).

Which of the following represent effective planning of the interview setting? Select all that apply. 1. Keep the lighting dimmed so as not to stress the client's eyes. 2. Ensure that no one can overhear the interview conversation. 3. Stand near the client's head while he or she is in the bed or chair. 4. Keep approximately 3 feet from the client during the interview. 5. Use a standard form to be sure all relevant data is covered

2,4, 5 Rationale: The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client's personal space is about 3 feet. Using a standard form will help ensure the nurse doesn't omit gathering any vital information. Lighting should be at a normal level—neither bright nor dim (option 1). The nurse should be at the same height as the client, usually sitting, at approximately a 45° angle facing the client. The nurse standing over the client creates an uncomfortable atmosphere for an interview (option 3).

For a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading? 1. 10-20 seconds 2. 30-45 seconds 3. 1-1.5 minutes 4. 3-3.5 minutes

2. Rationale: If the cuff is inflated to about 30 mmHg over previous systolic pressure, that would be 168. To ensure that the diastolic has been determined, the cuff should be released slowly until the mid60s mmHg (and then completely) for someone with a previous reading of 74. The cuff should be deflated at a rate of 2 to 3 mm per second. Thus, a range of 90 mmHg will require 30 to 45 seconds

Immediately after the parents of a hospitalized child are informed that the child has leukemia, the father responds by continuing his usual work schedule, rarely visiting, and asking when the child can return to school. Of the following, which is the least likely to be an appropriate nursing diagnosis at this time? 1. Ineffective Denial 2. Caregiver Role Strain 3. Fear 4. Compromised Family Coping

2. Rationale: It is too soon for Caregiver Role Strain to be an appropriate nursing diagnosis—especially since the child is not at home. Ineffective Denial and Fear are common reactions to this type of threat (options 1 and 3). The father demonstrates Compromised Family Coping by his difficulty in being supportive (option 4

A client in a cardiac rehabilitation program says to the nurse, "I have to eat a low-sodium diet for the rest of my life, and I hate it!" Which is the most appropriate response by the nurse? 1. "I will get a dietary consult to talk to you before next week." 2. "What do you think is so difficult about following a low-sodium diet?" 3. "At least you survived a heart attack and are able to return to work." 4. "You may not need to follow a low-sodium diet for as long as you think."

2. The nurse recognizes the need to obtain further information from the client in order to respond directly to the client's statement. Option 1 passes off the client's educational needs to another practitioner. Options 3 and 4 are nontherapeutic.

A client complains of shortness of breath. During assessment the nurse observes that the client has edema of the left leg only. The nurse reviews evidence-based practice literature and reflects on a previous client with the same clinical manifestations. What do these actions represent? 1. Clinical judgment 2. Clinical reasoning 3. Reflection 4. Intuition

2. rationale: Reviewing evidence-based literature and identifying similarities in the clinical manifestations of symptoms is an act of clinical reasoning. Past experiences in care enhance the nurse's ability to recognize and respond in the delivery of client-centered care. Clinical judgment in nursing is a decision-making process to ascertain the right action to implement at the appropriate time during client care (option 1). Reflection is the nurse's review of the care provided to determine strategies to improve future care (option 3), Intuition is a problem-solving approach that relies on a nurse's inner sense (option 4).

A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin? 1. Soak her feet frequently. 2. Use a non-perfumed lotion. 3. Apply foot powder. 4. Avoid knee-high elastic stockings

2. Rationale: A lotion will help moisten the skin. Perfumed lotions contain alcohol, which is drying to the skin. Soaking the feet for a long time or frequently also causes dry skin (option 1). Applying foot powder is appropriate to prevent or control unpleasant foot odor (option 3). Elastic stockings may decrease circulation (option 4).

The nurse is communicating with a primary care provider about medical interventions prescribed for a client. Which statement is most representative of a collaborative relationship? 1. "That new medication you prescribed for Mr. Black is ineffective." 2. "I am worried about Mr. Black's blood pressure. It is not decreasing even with the new antihypertensive medication." 3. "Can we talk about Mr. Black?" 4. "Excuse me doctor. I think we need to talk about Mr. Black's blood pressure."

2. Rationale: Option 2 uses an "I" statement, which is assertive communication and is clear and direct. The message includes only the necessary information. Option 1 contains inflammatory language ("ineffective" and "you prescribed"). Options 3 and 4 do not provide the health care provider with specific information and could stimulate defensive behaviors

The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following? 1. Shallow respirations 2. Wheezing 3. Shortness of breath 4. Coughing up blood

3 Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed. Option 1: Shallow respirations are seen in tachypnea (rapid breathing). Option 2: Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea. Option 4: The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea

The nurse determines that a field remains sterile if which of the following conditions exist? 1. Tips of wet forceps are held upward when held in ungloved hands. 2. The field was set up 1 hour before the procedure. 3. Sterile items are 2 inches from the edge of the field. 4. The nurse reaches over the field rather than around the edges.

3 Rationale: All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas. When hands are ungloved, forceps tips are to be held downward to prevent fluid from becoming contaminated by the hands and then returned to the sterile field (option 1). Fields should be established immediately before use to prevent accidental contamination when not observed closely (option 2). Reaching over a sterile field increases the chances of dropping an unsterile item onto or touching the sterile field (option 4).

The nurse is communicating with a well-oriented older adult client in a long-term care setting. Which statement best reflects respectful and caring communication? 1. "Are we ready for our shower?" 2. "It's time to go to the dining room, honey." 3. "Are you comfortable, Mrs. Smith?" 4. "You would rather wear the slacks, wouldn't you?"

3 Rationale: All of the other options are forms of elderspeak.

Which one of the following is an example of the emotional component of wellness? 1. The client chooses healthy foods. 2. A new father decides to take parenting classes. 3. A client expresses frustration with her partner's substance abuse. 4. A widow with no family decides to join a bowling league

3 Rationale: Frustration is an example of an emotion. The client who chooses healthy foods (option 1) represents the physical component, taking parenting classes enhances the intellectual component (option 2), and the bowling league (option 4) enhances both the physical and social components

In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1. Collects subjective data. 2. Applies a framework to the collected data. 3. Confirms data are complete and accurate. 4. Records data in the client record.

3 Rationale: In validating, the nurse confirms that data is complete and accurate. Subjective data is collected in the collecting activity (option 1), a framework is applied to the data in the organizing activity (option 2), and data is recorded in the documenting activity (option 4).

When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1. Sports contribute to an adolescent's self-esteem. 2. Sunbathing and tanning beds can be dangerous. 3. Guns are the most frequently used weapon for adolescent suicide. 4. A driver's education course is mandatory for safety.

3 Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver's education course does not ensure safe practice.

To palpate lymph nodes, the nurse uses which technique? 1. Use the flat of all four fingers in a vertical and then side-toside motion. 2. Use the back of the hand and feel for temperature variation between the right and left sides. 3. Use the pads of two fingers in a circular motion. 4. Compress the nodes between the index fingers of both hands.

3 . Rationale: Use the pads of two fingers and a gentle rotating motion over the nodes. None of the other options is proper palpation of lymph nodes.

A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? 1. Risk for Suffocation 2. Risk for Injury 3. Risk for Poisoning 4. Risk for Disuse Syndrome

3 A home that was built prior to 1978 has leadbased paint. The ingestion of lead-based paint chips places that child at risk for elevated serum lead levels and neurologic deficits. The most appropriate nursing diagnosis for this child is Risk for Poisoning. Option 1: The risk for suffocation is greater in infants and is not related to a home with lead-based paint. Options 2 and 4 are not related to leadbased paint.

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1. Proposes hypotheses. 2. Generates desired outcomes. 3. Reviews results of laboratory tests. 4. Documents care.

3 During assessment, data are collected, organized, validated, and documented. Hypotheses are generated during diagnosing; outcomes are set during planning; and documentation occurs throughout the nursing proces

If the client reports loss of short-term memory, the nurse would assess this using which one of the following? 1. Have the client repeat a series of three numbers, increasing to eight if possible. 2. Have the client describe his or her childhood illnesses. 3. Ask the client to describe how he or she arrived at this location. 4. Ask the client to count backward from 100 subtracting

3 Rationale: Recent memory includes events of the current day. Recalling a series of numbers tests immediate recall (option 1). Recalling childhood events tests remote (long-term) memory (option 2), and subtracting backwards from 100 tests attention span and

An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1. Leave the bathroom light on. 2. Withhold the client's diuretic medication. 3. Provide a bedside commode. 4. Keep the side rails up

3 Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls. Option 1: Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of fall when rushing to the bathroom. Option 2: The nurse cannot withhold a client's medication without consulting with the primary care provider. Option 4: If the client has orders to be up with assistance and the side rails are up, he is at risk for falls as well as falling from a greater distance.

Which client meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse? 1. A client who is in shock 2. A client whose pulse changes with body position changes 3. A client with an arrhythmia 4. A client who had surgery less than 24 hours ago

3 The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia. For clients in shock, use the carotid or femoral pulse (option 1). The radial pulse is adequate for determining a change in the orthostatic heart rate (option 2). The radial pulse is appropriate for routine postoperative vital sign checks with regular pulses

In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform? 1. Wear a mask during dressing changes. 2. Provide disposable meal trays and silverware. 3. Follow standard precautions in all interactions with the client. 4. Use surgical aseptic technique for all direct contact with the client.

3 Rationale: Standard precautions include all aspects of contact precautions with the exception of placing the client in a private room. A mask is indicated when working over a sterile wound rather than an infected one (option 1). Disposable food trays are not necessary for clients with infected wounds unlikely to contaminate the client's hands (option 2). Sterile technique (surgical asepsis) is not indicated for all contact with the client (option 4). The nurse would utilize clean technique when dressing the wound to prevent introduction of additional microbes.

Place the following descriptions of the helping relationship phases in the correct sequence. 1. After introductions, the nurse asks, "What plans do you have for the upcoming holiday weekend?" 2. The nurse states, "It sounds like you are concerned about the possible complications of having diabetes. What would be the most helpful for you at this time?" 3. The nurse reads in the medical history that the client was diagnosed with diabetes 1 week ago. 4. The nurse states, "When we met, you knew very little about diabetes and now you are able to use your new information and apply it to your own personal situations."

3, 1, 2, 4 Rationale: During the preinteraction phase (option 3), the nurse gathers information about the client before meeting the client. During the introductory phase (option 1), the nurse usually engages in some social interaction to put the client at ease. During the working phase (option 2), the nurse helps the client to explore feelings and helps the client plan a program. During the termination phase (option 4), the nurse summarizes or reviews the process that took place

Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply. 1. Hire only competent nurses. 2. Improve the nurse's ability to multitask. 3. Establish a reporting system for "near misses." 4. Communicate effectively. 5. Create a culture of trust.

3, 4, 5 Rationale: Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. Options 1 and 2 are inappropriate answers. A competent nurse may make medication errors. Also, evidence is needed to support these conclusions.

An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? Select all that apply. 1. Oral 2. Rectal 3. Axillary 4. Tympanic 5. Temporal artery

3, 4, and 5 Rationale: For this client, the nurse could take an axillary, tympanic, or temporal artery temperature. Due to the facial drooping and difficulty swallowing, the oral route is not recommended (option 1). Although the rectal route could be used, it would require unnecessary moving and positioning of a client who cannot assist, and it would not provide a significant advantage over the other routes (option 2)

Although not every client progresses in order through each stage, what is the usual sequence in Suchman's stages of illness? 1. The client makes contact with medical care. 2. The client goes into rehabilitation/recovery. 3. Signs and symptoms appear. 4. The client takes on the dependent role. 5. The client takes on the sick role.

3, 5, 1, 4, 2

A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client? 1. Totally dependent (+4) 2. Moderately dependent (+3) 3. Semidependent (+2) 4. Independent (0)

3. Rationale: The client fits the descriptors for a semidependent functional level

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? 1. Report the fire. 2. Extinguish the fire. 3. Protect the clients. 4. Contain the fire.

3. Rationale: In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire

The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client? 1. Presence of pain 2. Condition of the skin 3. Gag reflex 4. Range of motion

3. Rationale: The client will be positioned in a side-lying position with the head of the bed lowered because the client is at risk for aspiration. The absence of the gag reflex lets the nurse know that the client has no natural defense (cough) and is at a higher risk for aspiration. All other answers are assessments more appropriate prior to bathing the client

A client informed of a cancer diagnosis assures the nurse he is fine. Which of the following is the most indicative physical evidence to the nurse of the client's stress? 1. Constricted pupils 2. Dilated peripheral blood vessels (flush) 3. Hyperventilation 4. Decreased heart rate

3. Rationale: With stress, respirations increase, pupils dilate, peripheral blood vessels constrict, and the heart rate increases.

After the death of several long-term clients, which action indicates the nurse is demonstrating ineffective coping? 1. The nurse talks at length to her partner about the deaths. 2. The nurse keeps busy with other actions and doesn't think about the deaths for several days. 3. The nurse offers to work extra shifts for several weeks. 4. Several nurses schedule a group session with the agency clergy to discuss the deaths.

3. rationale: Rationale: Taking on additional work would only serve as an additional stressor. In addition, a nurse who has not begun resolution of feelings is unlikely to be able to meet clients' emotional needs. Effective coping may include verbalizing feelings (one-on-one or in groups) or initiating distractions (options 1, 2, and 4). Of course, the nurse may not disclose confidential information to her partner or others who would not already have this information.

The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1. "What did the doctor tell you about your diagnosis?" 2. "Are you worried about how the diagnosis will affect you in the future?" 3. "Tell me about your reactions to the diagnosis." 4. "How is your family responding to the diagnosis

3. rationale: Eliciting feelings requires an open-ended question that does more than seek factual information (option 1) and cannot be answered with a single word (option 2). The family can provide indirect information about the client, but is not most likely to provide the most accurate information (option 4).

In the clinical reasoning process, the nurse sets and weighs the criteria, examines alternatives, and performs which of the following before implementing a plan? 1. Reexamines the purpose for making the decision. 2. Consults the client and family members to determine their view of the criteria. 3. Identifies and considers various means for reaching the outcomes. 4. Determines the logical course of action should intervening problems arise.

4 Rationale: It is important to project what problems might interfere with the plan and have appropriate responses prepared to prevent the interferences. The purpose for the decision should have been clear enough at the outset as to not require reexamination at this point (option 1). Clients and families should be consulted early—in the purpose-setting and criteria-setting steps. Criteria should not be set until all significant participants have an opportunity to present their point of view (option 2). Considering various means for reaching the outcomes is the same as examining alternatives (option 3).

While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm (1/4 in.). What is the best action for the nurse to take? 1. Remove the glove and start over with a new pair. 2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand. 3. Ask a colleague to assist by unrolling the cuff. 4. Leave the cuff rolled under.

4 Rationale: It should not be necessary to unroll this small edge of the cuff. The most important consideration is the sterility of the fingers and hand that will be used to perform the sterile procedure. The rolled-under portion is now contaminated and should not be unrolled by the nurse or colleague since it would then touch the remaining sterile portion of the gl

A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following? 1. Bounding radial pulse 2. Irregular apical pulse 3. Carotid pulse stronger on the left side than the right 4. Absent posterior tibial and pedal pulses

4 The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals. Option 1: A bounding radial pulse is more indicative that perfusion exists. Options 2 and 3: Apical and carotid pulses are central and not peripheral

Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1. Keep all of the side rails up. 2. Review prescribed medications. 3. Complete the "get up and go" test. 4. Place the bed in the lowest position.

4 . Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of a bed that is at an appropriate height. Option 1 can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Option 2 is important to do as certain medications can increase the risk of falling; however, this is not the best answer because it is not applicable to all clients. Option 3 would help the nurse to assess a client's risk for falling but would not prevent injury.

The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client. Which action indicates that the nurse needs to discuss additional teaching with the UAP? 1. Uses a clean portion of the washcloth for each stroke 2. Wipes from the pubis to the rectum 3. Uses clean gloves 4. Does not retract the foreskin

4 .Rationale: It is important to retract the foreskin to remove the smegma that collects under the foreskin and can cause bacterial growth.

Which reasoning process describes the nurse's actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes? 1. Intuition 2. Research process 3. Trial and error 4. Problem solving

4 Rationale: A nurse thinks critically, evaluates possible solutions, and uses problem solving. Intuition (option 1) is not a sufficient basis for implementing wound care when significant data on alternative care strategies are available. Research (option 2) is a more comprehensive rigorous process and not typically implemented while caring for an infected wound. Trial and error (option 3) is unsafe and inappropriate for care of an infected wound

Which of the following is an internal variable affecting health status, beliefs, or practices? 1. Living situation 2. Socioeconomic status 3. Family structure 4. Genetics

4 Rationale: Genetics is an internal variable affecting health. Options 1, 2, and 3 are all external variables.

Which of the following would be true regarding use of the observing method of data collection? 1. When observing, the nurse uses only the visual sense. 2. Observing is done only when no other nursing interventions are being performed at the same time. 3. Data should be gathered as it occurs, rather than in any particular order. 4. Observed data should be interpreted in relation to other sources of collected data.

4 Rationale: Interpreting collected data is necessary to help validate its accuracy. Observing includes the senses of smell, hearing, and touch in addition to vision (option 1). Using priority setting, observing must often be performed simultaneously with other activities (option 2). A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first (option 4).

Which of the following is least likely to influence a client's personal definition of health/wellness? 1. The client's ability to perform his or her usual activities 2. The cultural traditions the client uses in everyday life 3. The availability and accessibility of health care services appropriate for the client's health condition 4. The medical diagnostic terminology used to describe the patient's medical condition

4 Rationale: The actual term used to describe the diagnosis is less important because the client may have no frame of reference for it. That is not to say that the diagnosis is unimportant because clients may be familiar with common diagnoses such as heart disease or cancer and ascribe historical meaning to them. Ability to perform usual activities, culture, and availability of health care will all be strong influences on the client's definition of health or wellness

The nurse positions the client sitting upright during palpation of which area? 1. Abdomen 2. Genitals 3. Breast 4. Head and neck

4 Rationale: The client should sit for examination of the head and neck. For palpation of the abdomen (option 1), genitals (option 2), and breast (option 3), the client should be supine

If the client can accurately read only the top three lines, what would be an appropriate nursing diagnosis? 1. Deficient Knowledge 2. Impaired Memory 3. Ineffective Tissue Perfusion 4. Risk for Injury

4 rationale: If the client can only read the first three lines, vision is impaired and could lead to falls or other injuries. This impaired vision is not related to deficient knowledge (option 1) or memory (option 2) and may or may not be related to circulation (option 3).

For a client whose assessment of the musculoskeletal system is normal, which does the nurse check on the medical record? (Select all that apply.) 1. Atrophied 2. ____ Contractured 3. ____ Crepitation 4. ____ Equal 5. ____ Firm 6. ____ Flaccid 7. ____ Hypertrophied 8. ____ Spastic 9. ____ Symmetrical 10. ____ Tremor

4 equal, 5 firm, and 9 symmetrical

The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client? 1. Open bed in low position 2. Occupied bed in low position 3. Closed bed in high position 4. Surgical bed in high position

4. . Rationale: Both the placement of the linens for a surgical bed and placing the bed in a high position facilitate the client's transfer from a stretcher into the bed. The linens for a closed bed are drawn up to the top of the bed and under the pillows (option 3)

The client made the following statement to the nurse, "My doctor just told me that he cannot save my leg and that I need to have an above-the-knee amputation." Which response by the nurse is most appropriate? 1. "Dr. Jones is an excellent surgeon." 2. "Are you in pain?" 3. "If I were you, I'd get a second opinion." 4. "Tell me more. . . ."

4. Option 4 is a therapeutic technique using an open-ended question that allows the client to elaborate. The other options are barriers to communication. Option 1 is incorrect because the client did not ask about the abilities of the surgeon and the response does not focus on the client. Option 2 is changing the subject, and option 3 is giving advice.

A 75-year-old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? 1. Restrain the client in bed. 2. Ask a family member to stay with the client. 3. Check the client every 15 minutes. 4. Use a bed exit safety monitoring device.

4. Rationale: Option 4 is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option 1 can increase agitation and confusion and removes the client's independence. Option 2 would help but transfers the responsibility to the family member. Option 3 is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse.

The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1. Correlation of the data with other members of the health care team 2. Demonstration of cost-effective care 3. Utilization of creativity and intuition in creating a plan of care 4. Collection of all necessary information for a thorough appraisal

4. rationale: Frameworks help the nurse be systematic in data collection. Other members of the health care team may use very different conceptual organizing frameworks so data may not correlate (option 1). Cost-effective care (option 2) is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured (option 3)

When the nurse enters a client's room to measure routine vital signs, the client is on the phone. What technique should the nurse use to determine the respiratory rate? 1. Count the respirations during conversational pauses. 2. Ask the client to end the phone call now and resume it at a later time. 3. Wait at the client's bedside until the phone call is completed and then count respirations. 4. Since there is no evidence of distress or urgency, postpone the measurement until later.

4. Rationale: Since the client's needs are always considered first, the measurement should be delayed unless the client is in distress or there are other urgent reasons. Option 1: Respirations should be measured for 30 seconds to 1 minute and are affected by talking. Option 2: There needs to be an important reason for interrupting the client. Option 3: It is inappropriate to wait and listen to the client's conversation.

The first time the nurse enters the client's room, the client is on the phone. Immediately, the client slams down the phone, sweeps everything off the overbed table, and demands that the nurse perform several duties "this very minute." Which of the following would be the most appropriate response for the nurse? 1. Tell the client "I will return" and then leave the room. 2. Tell the client no care will be given until the screaming ends. 3. Begin providing needed care calmly and quietly. 4. Allow the client to complete venting, then respond calmly.

4. Rationale: Unless the nurse feels in physical danger, it is important to remain with the client, allow the anger to dissipate, and then begin assessing the cause. Leaving the room provides no therapeutic action (option 1). Option 2 may be considered setting limits, which can be helpful, but cannot occur until the client is calmer. All behavior is meaningful; it is inappropriate to ignore the client's behavior (option 3).

The nurse helps a 50-year-old client with diabetes who is to begin giving insulin injections identify previously successful coping strategies that may be useful in the current situation. Which stressor is closely related to the new stressor? 1. Interviewing for a new job 2. Death of a pet while the person was a teenager 3. The person's partner filing for a divorce 4. Starting to wear eyeglasses at age 30

4. Rationale: Wearing glasses is another example of beginning a new strategy to assist with what will be a lifelong health need even though it is not necessarily a desired change. Interviewing for a job (option 1) is a very short-lived situational stressor. Coping strategies effective while a teenager may not be relevant at age 50 (option 2). Experiencing the stress of a divorce is a social/role stressor quite unlike that of a health problem (option 3

A student nurse is caring for a 72-year-old client with Alzheimer's disease who is very confused. Which is the most appropriate communication strategy to be used by the student nurse? 1. Written directions for bathing 2. Speaking very loudly 3. Gentle touch while providing ADLs 4. Flat facial expression

answer = 3 Rationale: Nonverbal, gentle touch is an important tool; overstimulation may affect the client in a negative way. Option 1: Written communication requires a higher level of consciousness than verbal. Option 2: The client does not have a hearing problem but lacks the ability to interpret and understand communication. Option 4: Lack of facial expression may increase fear

A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be _____________.

risk for infection