2/5/23 (HURST)

During a yearly checkup, an adult client asks the Healthcare Provider to examine a mole which has recently become bothersome. The HCP is concerned about the appearance of the mole and refers the client to a specialist. The nurse is asked to assemble the documents to be sent with the client. The nurse knows what documents are important to send to the specialist? 1. The most recent history and physical findings. 2. History of childhood diseases and vaccinations. 3. List of all current medications and allergies. 4. X-ray results of last year's broken clavicle. 5. Insurance info with consent for release. 6. Current diagnoses and treatments

1, 3 & 5. Correct: A recent history and physical will provide the specialist with a brief overview of the client's present health status, including any previously noted changes in the skin. Healthcare providers always ask about current medications along with a list of known allergies. Such health details provide a basis for any new information discovered by the specialist. Insurance information with consent to release that information is standard in most healthcare facilities and among healthcare providers. 2. Incorrect: This client is an adult with a skin anomaly requiring special evaluation. Childhood diseases and/or vaccinations would not be necessary for the treatment of this skin anomaly. 4. Incorrect: The client's referral is based on a suspicious mole requiring specialized treatment. An X-ray summary of a non-related fracture would not be pertinent to that situation. 6. Incorrect: It is not necessary to send information on current diagnoses or treatments to the specialist. Such information is not pertinent to the condition for which the client was referred and may violate privacy rights. If the specialist determines the client will need medication or other actions for the skin growth, then further information regarding current health treatments can be obtained at that point.

Which assessment finding by the nurse is most indicative of fluid volume overload? 1. Client has pitting edema in lower extremities. 2. Client's blood pressure is 120/80. 3. Client's CVP measurement is 6 mmHg. 4. Weight gain of 1.5 pounds (0.68 kg) in one day.

1. Correct. A client in fluid volume overload may experience pitting edema in lower extremities, a bounding pulse, increased blood pressure, and shortness of breath. 2. Incorrect. This blood pressure reading is considered normal and is not a characteristic of fluid volume overload. 3. Incorrect. This CVP is within the normal range therefore not indicative of a fluid volume excess. In a fluid volume excess, the CVP would be elevated. 4. Incorrect. A weight gain in excess of 2 pounds (0.9 kg) is of concern for fluid volume excess. Any weight gain overnight is reason for concern; however, the stem asked which finding was most indicative.

A client diagnosed with renal failure has been admitted to the medical unit. An arterial blood gas (ABG) analysis has been prescribed by the primary healthcare provider. Which ABG interpretation by the nurse is appropriate? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Correct: Metabolic acidosis pH - 7.33 (normal value 7.35 - 7.45) less than 7.35 PaCO2 36 mm Hg (normal value 35 - 45 mm Hg) within normal range HCO3 20 mEq/L (normal value 22 - 26 mEq/L) less than 22 mEq/L Metabolic acidosis is reflected in a reduction of the HCO3 and pH levels. 2. Incorrect: Metabolic alkalosis is indicated by an elevated pH and HCO3 levels. The client's HCO3 and the pH are below the normal range. 3. Incorrect: The primary issue with respiratory acidosis is an elevated CO2 level. The CO2 level for this client is within the normal range. 4. Incorrect: With respiratory alkalosis the pH is greater than 7.45. The pH for this client is less than 7.35 and the PaCO2 is within the normal range. The HCO3 value will decrease or elevate depending if the pulmonary process is acute or chronic.

The nurse is reviewing medications for a client who is being treated for major depression. The client is prescribed a selective serotonin reuptake inhibitor (SSRI). Which over the counter medication/supplement taken by the client should be reported to the primary healthcare provider immediately? 1. Daily intake of St. John's Wort. 2. Daily intake of a multi-vitamin. 3. Occasional use of ibuprofen. 4. Twice daily intake of an antacid.

1. Correct: St. John's Wort is an herbal supplement often used in the treatment of mild depression. It should not be taken in combination with a selective serotonin reuptake inhibitor due to the risk of serotonin syndrome, which can be fatal. 2. Incorrect: A multi-vitamin taken with an SSRI poses no risk. 3. Incorrect: This medication taken with the SSRI would not warrant immediate reporting to the primary healthcare provider. 4. Incorrect: Antacids would not require immediate reporting.

The home health nurse is concerned about the safety of the client who lives alone in a poorly maintained home. The nurse convenes the interdisciplinary team to discuss the situation. Which action should occur first? 1. Share the assessment findings with the interdisciplinary team. 2. Suggest that the social worker visit the client in the home. 3. Ask the primary healthcare provider about possible nursing home placement. 4. Suggest a "meals on wheels" solution to nutrition.

1. Correct: The assessment findings from the home health nurse will allow each person of the team to offer input based on their particular expertise. After assessment findings have been discussed, the problem solving approach can begin. The interdisciplinary team works together and shares their expertise, knowledge and skills to improve client care. 2. Incorrect: Suggesting a social worker visit may be appropriate; however, this situation would best be served by a discussion with the entire team first. 3. Incorrect: Nursing home placement may be appropriate; however, this is not the first step in collaboration with the team. The team will discuss the home health nurse's concerns and problem solve to provide solutions. 4. Incorrect: Nutrition is a pertinent issue that may need to be addressed; however, the entire team's input is needed at this point. Also the nurse's concern in the safety of the client in a poorly maintained home.

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

1. Correct: This client has developed signs of cardiogenic shock, one of the complications post CABG. Cardiac output is decreased, so the client needs more oxygen for the circulating blood volume. 2. Incorrect: Lowering the HOB will not help in cardiogenic shock but will actually make it harder for the heart to pump. It will increase the workload of the heart. 3. Incorrect: Poor kidney perfusion is the reason for the decreased UOP. The kidneys are trying to conserve what little volume the body has to maintain vital organ perfusion as long as possible. Furosemide will make the client lose more volume, which can kill the client. 4. Incorrect: Rechecking the BP will not help the problem. With the other symptoms, this BP is most likely accurate. This would only delay treatment and would not fix the problem

The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates the action? 1. The client has the right to a safe care environment. 2. The nurse may be sued for malpractice if injury occurs. 3. All clients on mental health units are placed on suicide precautions. 4. Clients are most likely to act on suicidal thoughts when energy is low.

1. Correct: Verbalizing suicidal thoughts is a risk factor for client suicide. Safety must be maintained while the client is in this vulnerable state. The nurse identifies client at risk of suicide and intervenes to prevent harm for those identified as being at risk. 2. Incorrect: Client safety is the primary issue here. 3. Incorrect: This is not a true statement. All clients have the right to a safe environment; however, not all clients on the mental health unit are placed on suicide precautions. Only clients identified at risk for suicide are placed on suicide precautions. 4. Incorrect: This is an untrue statement. Clients are likely to act on suicidal thoughts as energy levels improve. The issue here is client safety, and the client's right to a safe environment.

Which intervention would the nurse recommend to a client with rheumatoid arthritis to best help relieve joint stiffness? 1. Take a warm shower prior to performing activities of daily living. 2. Take an aspirin after activity to help decrease inflammation. 3. Lose 10 pounds of weight. 4. Apply cold compresses to joints for 30-45 minutes.

1. Correct: Warm water may provide muscle relaxation, increase blood flow, and reduce stiffness. 2. Incorrect: A mild analgesic may be taken before activity or exercise to decrease pain and inflammation. 3. Incorrect: Weight reduction may be recommended to relieve stress on joints but does not address joint stiffness. 4. Incorrect: Apply cold compresses for 15-20 minutes at a time. Longer than 20 minutes may cause tissue damage.

The nurse is participating in a presentation regarding adolescent violence to middle and high school faculty and staff. What risk factors for violence should the nurse include? 1. Attention deficit disorder 2. Diminished economic opportunities 3. Authoritative parenting style 4. Active in school sports 5. High parental involvement

1., & 2. Correct: School learning problems such as attention deficit disorder, low IQ, and poor academic achievement can lead to poor self-esteem, increased stress and risk for becoming a victim or perpetrator of violence. Low socioeconomic status and low job opportunities contribute to a poor community with a high level of poor residents. This a community based risk factor. 3. Incorrect: Authoritarian childrearing parenting style is a family risk factor for becoming a victim or perpetrator of violence. Authoritarian parenting consists of a relationship that is controlling, power-assertive, and high in unidirectional communication. 4. Incorrect: Lack of involvement in conventional school and community activities is a social risk factor for becoming a victim or perpetrator of violence. 5. Incorrect: Low parental involvement in the child's life is a family risk factor risk for becoming a victim or perpetrator of violence.

The nurse is caring for a client being treated for hypertensive crisis and suspects that the client may be developing an abdominal aortic aneurysm (AAA). Which assessment findings by the nurse suggest that the client is developing this complication? 1. Abdominal bruit 2. Upper back pain 3. Hoarseness 4. Pulsations around umbilicus 5. Shortness of breath

1., & 4. Correct. A bruit heard over the abdomen is an indicator of an abdominal aortic aneurysm and warrants further investigation. An abdominal aortic aneurysm usually causes a balloon-like swelling. The wall of the aorta bulges out which results in a pulsating mass in the abdomen. 2. Incorrect. Upper back pain is not associated with AAA but rather with a thoracic aneurysm. 3. Incorrect. Hoarseness can be caused by any number of disorders, but not AAA. It can be seen with a thoracic aneurysm. 5. Incorrect. Shortness of breath is indicative of a respiratory problem but can be seen with a thoracic aneurysm. It is not a symptom of AAA.

What signs/symptoms would the nurse expect to assess in a client diagnosed with tabes dorsalis neurosyphilis due to untreated syphilis? 1. Abnormal gait 2. Blindness 3. Hyperreflexia 4. Stiff neck 5. Hearing loss

1., 2. Correct: Symptoms of tabes dorsalis are caused by damage to the nervous system. Problems walking occur such as an abnormal gait or inability to walk at all. Vision changes can occur. Blindness is a complication of tabes dorsalis. 3. Incorrect: Loss of coordination and diminished reflexes occur rather than hyperreflexia. 4. Incorrect: Stiff neck is seen with meningitis, but also with meningovascular neurosyphilis. Meningeal neurosyphilis usually manifests with the clinical features of acute meningitis. 5. Incorrect: Hearing is not affected by neurosyphilis. However, vision changes, including blindness can occur.

The homecare nurse is instructing a client with chronic obstructive pulmonary disease (COPD) about the importance of a nutritious diet to avoid weight loss. The nurse knows that teaching has been effective when the client selects which foods for a breakfast menu? 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast

1., 2., 3. & 4. Correct: Maintaining weight and nutrition is vital to the health of clients with (COPD). Extreme fatigue along with excessive mucus production decreases the client's ability to eat complete, well-balanced meals, leading to weight loss or malnourishment. Therefore, the nurse would instruct the client to eat small, frequent meals high in protein and fiber. Good sources of protein include eggs, cheese, fish and poultry, beans and even nuts. Fresh fruit such as bananas along with non-carbonated beverages such as orange juice are excellent breakfast food choices. 5. Incorrect: Although milk and dairy products like yogurt could be considered part of a healthy breakfast, it is recommended that COPD clients use 1% or 2 % milk products to avoid increasing mucus production. This client should select the orange juice from the choices provided. 6. Incorrect: Dry toast provides little nutrient value, and may actually increase coughing because of its brittle nature. Coughing quickly leads to exhaustion rather than eating. This client would benefit more from a more palatable choice such as muffin or French toast.

The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking

1., 2., 4., 5., & 6. Correct: These are all modifiable risk factors that can be managed through lifestyle changes or medical treatment. 3. Incorrect: Hispanics, African Americans, Native Americans, and Asian Americans have a higher incidence of strokes than whites. You cannot change your race or ethnicity so this is a non-modifiable risk factor for stroke.

What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis? 1. Effusion to knees. 2. Weight loss of 1 kg in 2 weeks. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.

1., 3., 4., & 5. Correct: As rheumatoid arthritis worsens, the joints become progressively inflamed and very painful. On palpation, these joints feel soft and look puffy because of synovitis and effusions, especially in the knees. Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. Peripheral neuropathy occurs in later stages of the disease due to vasculitis. Subcutaneous nodules or rheumatoid nodules are firm bumps of tissue most commonly form around pressure points, such as the elbows. 2. Incorrect: A 1 kg weight loss over 2 weeks would more likely occur in the early stages of the disease. As the disease progresses, there is moderate to severe weight loss and accompanying anemia.

When teaching a client about lactose intolerance, what should the nurse include? 1. Common symptoms of lactose intolerance include abdominal bloating, diarrhea, and gas. 2. Symptoms of lactose intolerance generally occur three hours after consuming foods high in lactose. 3. Calcium rich foods should be consumed. 4. The client can drink lactose-free milk. 5. Vitamin D foods should be increased in the diet.

1., 3., 4., & 5. Correct: These statements are correct. Symptoms include abdominal bloating, pain, diarrhea, and gas. Because milk and milk products cause symptoms, the client may not get enough calcium and vitamin D. Supplementing with calcium or foods high in calcium and vitamin D is important to maintain these levels. The client may have lactose-free milk. 2. Incorrect: Symptoms occur 30 minutes to 2 hours after drinking milk or milk products.

A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that teaching was successful? 1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 2. "Rather than drinking a glass of wine, I should drink a glass of beer." 3. "Losing weight can help reduce the uric acid levels in my blood." 4. "Potatoes, rice, and barley are high in purine and should be eliminated from my diet." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."

1., 3., 5., & 6. Correct: Foods that contain 150 mg or more of purine are considered high purine foods and should be eliminated from the diet. Weight loss has been shown to improve insulin resistance, and therefore reduce uric acid levels in the blood. Vegetables that have high purine content include cauliflower, spinach, peas, asparagus, and mushrooms. These should be limited to no more than 2 times per week. Ensuring a sufficient fluid intake helps to reduce the risk of crystals forming in joints. Keeping hydrated and avoiding dehydration can lessen this risk and help to prevent gout attacks. 2. Incorrect: Alcohol - These cause increased dehydration and interfere with uric acid elimination. The metabolism of alcohol in your body is thought to increase uric acid production, and alcohol contributes to dehydration. Beer is associated with an increased risk of gout and recurring attacks, as are distilled liquors to some extent. The effect of wine is not as well understood. 4. Incorrect: Potatoes, rice, barley, noodles, and pastas are low in purine and can contribute to the 4 or more servings of starches needed per day.

The nurse provides education to a client who is scheduled for an upper GI series. Which statement by the client indicates an understanding of the nurse's teaching? 1. "I'll have to take a strong laxative the morning of the test." 2. "I'll have to drink contrast while x-rays are taken." 3. "I'll have a CT scan after I'm injected with a radiopaque contrast dye." 4. "I'll have an instrument passed through my nose to my stomach."

2. Correct: In an upper GI series (sometimes called a barium swallow test), the client swallows barium contrast while x-rays are taken. 1. Incorrect: Laxatives are taken the night before a colonoscopy to ensure stool is cleared from the colon. Waiting to take the laxative the morning of the test would be ineffective and uncomfortable for the client. 3. Incorrect: Radiopaque dye injected before a CT (computed tomography) scan is not part of an Upper GI series. A CT scan with dye is used as a noninvasive diagnostic tool to assess for injuries or diseases. This exam takes multiple images and the dye helps make the tissue or organ examined more clearly. 4. Incorrect: A tube is not passed through the nasopharynx with an Upper GI series. In a gastroscopy (sometimes called a gastric endoscopy), a scope is passed through the mouth to the stomach to visualize the inner lining of the upper GI tract.

Which prevention measure should the nurse include when instructing a client on avoidance of otitis externa? 1. Gently cleaning the ear canal with a cotton tipped applicator daily. 2. Use of astringent drops after bathing. 3. Taking preventative antibiotics prior to swimming in lakes or ponds 4. Routine use of nasal saline to clear the sinuses and eustachian tubes.

2. Correct: Prevention and avoidance measures for otitis externa include thorough ear canal drying and use of acidifying or astringent drops after swimming or bathing. 1. Incorrect: Clients should be taught to NEVER stick objects, including cotton tipped applicators, into the ear canal. This could result in rupture of the tympanic membrane. 3. Incorrect: Taking preventative antibiotics is unnecessary and increases the risk for antibiotic resistance. 4. Incorrect: Use of saline may be useful in keeping the sinuses cleared thereby reducing accumulation in the eustachian tubes. While this might be beneficial for otitis media, it would serve no benefit in otitis externa.

The nurse is working on health promotion plans for a small group of school-aged children who are at risk for obesity. Which baseline data would support the risk for obesity? 1. Spends one hour playing sports or swimming daily. 2. Spends at least two hours watching TV after dinner each day. 3. Assists mom in preparing low carb snacks for the family. 4. Participates in the marching band at school.

2. Correct: Sedentary activities, such as watching television, playing video games and using a computer to surf the internet or engage with friends can also contribute to obesity and cardiovascular health problems in later life. 1. Incorrect: The more active the child is, the less likely he is to be overweight. Activity for at least one or more hours per day should be encouraged. 3. Incorrect: Children who are exposed to healthy snacks are less likely to be overweight and are more likely to choose healthy snacks. 4. Incorrect: The marching band is an excellent source of exercise for the child. This information does not support the risk for obesity.

.A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse? 1. One year old child who has a heart rate of 150 bpm and is crying 2. Two year old child who has a heart rate of 165 bpm and is being rocked 3. Five year old child who has a heart rate of 100 bpm and is playing quietly 4. Thirteen year old adolescent who has a heart rate of 90 and is watching television

2. Correct: The 2 year old child with a heart rate of 165 requires additional assessment. The normal heart rate for a 2 year old child is 80-120 beats per minute. This child is experiencing tachycardia that warrants further investigation. 1. Incorrect: Although a 1 year old's heart rate ranges from 80-130, the rate can increase to 150 with vigorous crying. If the child was at rest, a rate of 150 would warrant further investigation. 3. Incorrect: The normal heart rate for a 5 year old child is 70-100 beats per minute. 4. Incorrect: Teenagers have heart rates that generally range from 60-90 beats per minute. Children who are athletic may have even lower heart rates, especially at rest.

The nurse is caring for a client who has the diagnosis of schizophrenia. The nurse enters the room to administer the morning dose of the prescribed antipsychotic medication. The client is drooling and has extreme muscular rigidity. After assessing the client for adequate respiratory effort, what is the nurse's priority? 1. Elevate HOB and give the medication as prescribed. 2. Hold the medication and call the primary healthcare provider. 3. Report the behaviors to the on-coming shift. 4. Hold the medication, and check the vital signs.

2. Correct: The nurse should hold the medication, and report the symptoms to the primary healthcare provider. The client may be experiencing neuroleptic malignant syndrome. 1. Incorrect: The client is experiencing symptoms of possible neuroleptic malignant syndrome. The nurse should not give another dose of the medication without consultating with the primary healthcare provider. 4. Incorrect: The client may be experiencing neuroleptic malignant syndrome. It is important to notify the primary healthcare provider immediately. 3. Incorrect: The symptoms that the client has are very serious and should be reported to the primary healthcare provider immediately.

After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

2. Correct: This is an oxygen therapy safety precaution that the nurse should implement after applying oxygen. It is also the only correct and safe option in the question. 1. Incorrect: The bi-nasal prongs would mean that the oxygen is going in through the nose. Breathing deeply through the mouth and out through the nose would not increase oxygenation for a client having chest pain and would disrupt the flow of oxygen through the nose. 3. Incorrect: The nurse should avoid using petroleum products where oxygen is in use because they are flammable. 4. Incorrect: These client's actions have nothing to do with oxygen administration and would cause more distress to the client with chest pain.

The nurse enters a client's room to administer morning medications and notes that the client is praying aloud. What would be the nurse's best action? 1. Interrupt the client to administer the medications. 2. Wait quietly until the prayer is finished. 3. Join the client for the prayer. 4. Ask the client if you can provide a directed prayer.

2. Correct: This is the best action by the nurse as this is a private spiritual moment for the client. Prayer is a self-care strategy that provides comfort, increases hope, and promotes healing and psychological well-being. The nurse could either leave and return later or wait quietly for the client to finish. 1. Incorrect: Administering the medications can wait until the client finishes the prayer. 3. Incorrect: Do not assume that the client wants others to join in the prayer. This is a private moment for the client. 4. Incorrect: Do not assume that the client wants others to join in the prayer. Don't interrupt the client while praying.

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the caregivers, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water throughout the day. 4. Apply heating pad to bruised areas of the skin.

2. Correct:The greatest risk to clients following a transplant is the chance of infection from any source since the client is severely immune-compromised for an extended period of time. There are numerous precautions necessary to avoid bacteria, but one area of concern is food storage, preparation, and consumption. Raw fruits with no skin to peel, such as strawberries, and raw vegetables like broccoli and cauliflower, present a serious risk for bacterial contamination and should not be consumed by new transplant clients. 1. Incorrect: Precise mouth care is vital following a bone marrow transplant; however, rinsing a toothbrush in alcohol is unsafe. Any residual alcohol would cause irritation and trauma to gum tissue, placing the client at risk for mouth inflammation and infection. Clients are instructed to brush teeth twice daily with a soft bristle brush, using fluoride toothpaste. Some clients are instructed to soak the toothbrush once weekly in a special bleach solution, then rinse in hot water, while others need to replace the toothbrush weekly, based on lab test results. 3. Incorrect: Standing water of any type quickly builds up bacteria, including flower vases and vaporizers. Although bottled water may seem a safe choice, after that bottle is opened, bacteria begins to quickly build up, even if the bottle is recapped. Any water standing more than 15 minutes is considered old and must be thrown out. 4. Incorrect: With bone marrow transplant clients, it will be months before the body begins to stabilize and produce normal blood cells. Bruising and low platelet counts are to be expected for a period of time. When clients develop bruising, the approved treatment is cold compresses or ice packs applied for 15 minutes a couple of times per day, and never a heating pad. Additionally, the healthcare provider should be notified so that a current platelet count can be obtained.

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in

2., 3. & 5. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. However, there are some basic points which are standard among all facilities. This situation is considered an external disaster which means the hospital will be expecting multiple victims. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. These individuals are selected by the charge nurse, and do not have to be nurses. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. 1. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 4. Incorrect: This would unnecessarily alarm the clients. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client.

The nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include? 1. Rotavirus 2. Meningococcal 3. Herpes zoster 4. Seasonal influenza 5. Human papilloma virus

2., 4., & 5. Correct: Meningococcal vaccine protects against bacterial meningitis and is recommended for students entering college. Influenza vaccine is recommended annually for protection against the viruses predicted to be most common for the season. Human papilloma virus vaccine is recommended for protection against the virus which causes cervical and anal cancers. 1. Incorrect: Rotavirus vaccine is recommended during infancy. Rotavirus is the most common cause of diarrheal disease among infants and children. 3. Incorrect: Herpes zoster vaccine is recommended for adults, over the age of 60 to reduce the risk of getting shingles.

The client reports pain at the IV insertion site while Vancomycin is infusing. The nurse notes redness and swelling to the insertion site. Which action will the nurse take first? 1. Complete a pain assessment. 2. Stop the infusion. 3. Restart an IV. 4. Apply a warm compress to the site.

2.CORRECT. The infusion must be stopped first to prevent any further damage. 1.INCORRECT. While more information will be needed regarding the pain, this is not the first step to be completed. 3.INCORRECT. Based on the assessment in the stem of the question, a new IV is needed, but this is not the first step. 4.INCORRECT. A warm compress can be used to help decreased the redness and edema, but this will be done after the IV is removed. It is not the first step to be taken.

A client had an open cholecystectomy several days ago. What finding by the nurse should be reported to the primary healthcare provider immediately? 1. Respiratory rate of 30 2. Blood pressure reading of 104/50 3. Incisional pain with foul, green drainage 4. Urinary output of 75 mL straw colored urine

3. CORRECT: The client is having incisional pain, which by itself could be expected following an open cholecystectomy. However, there should never be any foul, green drainage from an incision, as this indicates a post-operative infection. The nurse should report this immediately to the primary healthcare provider. 1. INCORRECT: Although this respiratory rate seems slightly on the elevated side, this client has had recent surgery and is now having some complications. Combined with the pain, this rapid respiratory rate would be expected. 2. INCORRECT: There is no baseline data provided regarding this blood pressure data. Without a reference to a client's previous blood pressure, it is impossible to form any opinion about this reading. We worry about a systolic BP of 90. 4. INCORRECT: The information provided in the question does not give any parameters by which to evaluate the urine. Straw colored urine is a normal finding; however, there is no indication regarding the length of time it took to accumulate 75 mL of urine. Therefore, no decision can be formed about this finding.

Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? 1. Hemoglobin of 11 g/dL (110 g/L) (6.8266 mmol/L) 2. White Blood Cell count of 22,000 mm3 3. Hematocrit of 18% 4. Serum glucose of 80 mg/dL (4.44 mmol/L)

3. Correct: A hematocrit in postpartum women can drop as low as 20% (0.2) and not require transfusion in the absence of symptoms of hypovolemia. A hematocrit of 18% and lower should be reported even in the absence of dizziness, lightheadedness, shortness of breath with exertion, and syncope. 1. Incorrect: A hemoglobin of 11 g/dl (110 g/L) (6.8266 mmol/L) is considered to be normal for pregnancy and postpartum. 2. Incorrect: It is not unusual for a postpartum woman to have a WBC up to 25,000 mm3 without infection because of the healing process of the reproductive system. 4. Incorrect: Serum glucose of 80 m/dL (4.44 mmol/L) is within the normal range of glycemic control.

A nurse is receiving morning report on the cardiovascular unit. What client should be the nurse's priority assessment? 1. A client with ejection fraction of 20% and dyspnea at rest. 2. A client with a chest tube to suction and sub-q emphysema. 3. A client two days past abdominal aortic aneurysm repair with decreased pedal pulses. 4. A client coronary artery bypass graft three days ago with WBC 17,000 mm3.

3. Correct: An abdominal aortic aneurysm (AAA) is an enlarged area of the vessel which supplies blood to the entire body. Surgical repair of the aneurysm requires major surgery to remove the damaged portion and replace/reinforce the area with a graft or mesh. Most clients make a full recovery in a month or two. However, this client is only two days post-op, and now has decreased pedal pulses. This may indicate a rupture of the graft or another tear in the aorta with impaired circulation to the lower extremities. This client is the nurse's priority. 1. Incorrect: Ejection fraction is a measurement of the percentage of blood leaving the heart with each contraction. In a normal healthy adult client, the ejection fraction should be 55% or greater. This client has only 20% ejection fraction, indicating severely impaired heart pumping function and likely frequent episodes of CHF. The fluid backs up into the lungs; therefore, it is not unusual for such a client to be short of breath at rest. Since no actual respiratory rate is given, this client is not considered a priority. 2. Incorrect: Despite the sub-q emphysema, this client should be considered stable at this time. A chest tube is in place to suction, and it is not unusual to have sub-q emphysema following the insertion of a chest tube. No data suggests the client is unstable at this time. 4. Incorrect: This client had a coronary artery bypass graft (CABG) procedure three days ago. It is not unusual for the white count to be elevated. Though the level is significantly elevated and should be reported to the healthcare provider, the client is not a priority assessment for the nurse.

At what age does the nurse expect to see a child build a tower of 9 blocks? 1. One 2. Two 3. Three 4. Four

3. Correct: By the age of 3 years, the nurse would expect the child to build a tower of 9-10 blocks. 1. Incorrect: At one the child is working on gross motor skills rather than dexterity skills. 2. Incorrect: By age 2 the child can build a tower of at least 4 blocks. 4. Incorrect: The four year old can build high towers of more than 10 blocks

A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults.

3. Correct: Caffeine and some medications may interfere with sleep. 1. Incorrect. The client is concerned about the sleep problem, and the nurse should address the client's concerns. Sleep disturbances can also indicate depression. This option is denying their concerns. 2. Incorrect. Elders actually require less sleep because they are less active. Elderly do not need as much sleep. 4. Incorrect. Elders are likely to have more disturbed sleep. They usually do not need more sleep.

A client diagnosed with a right embolic stroke is admitted to the rehabilitation unit. The client is presenting with dysphagia. Which nursing intervention would the nurse implement for a client with dysphagia? 1. Flex the neck backwards 2. Request a liquid diet for the client 3. Place food on the right side of the mouth 4. Turn the client's plate around halfway through the meal

3. Correct: The client's neurological deficit will determine where to place the food in the person's mouth. The food should be placed on the right side of the mouth due to the client's left facial weakness. 1. Incorrect: The neck should be flexed forward. If the neck is flexed backward, food/liquids will have more difficulty moving through the esophagus to the stomach. The client's risk of aspiration into the trachea increases. 2. Incorrect: Liquid foods are not recommended on a dysphagia diet because liquid foods will increase the risk of aspiration. The client should eat foods that are softer in texture and thickened liquids to aid their ability to swallow. 4. Incorrect: Turning the plate is an intervention for homonymous hemianopsia. Homonymous hemianopsia is losing half of your visual field in one or both eyes. The client is exhibiting dysphagia, and is not experiencing a visual deficit. Turning the plate is not an intervention for dysphagia.

The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first? 1. Position client upright with right leg elevated. 2. Obtain wound culture before cleaning wound. 3. Assess current pain level and medicate. 4. Encourage client to verbalize concerns.

3. Correct: Wound care on burns is a painful process, particularly with partial thickness burns (formerly referred to as second degree) because nerve endings are intact and exposed. Pre-medicating is a priority action, since pain medication can take up to 30 minutes to activate within the body. Clients are more cooperative and heal faster when pain is well controlled. 1. Incorrect: Proper visualization during wound care is vital, as is client comfort during the procedure. However, completion of this process does not require the client to be in an upright position. In fact, that may be counter productive at this time. Additionally, whether the right leg needs elevated depends on the size or location of the burn on the right leg, and that information has not been provided in the question. 2. Incorrect: While it is true that any wound culture must be obtained prior to cleaning the affected area, this action is not presently the nurse's first priority. Consider the nursing process and choose another option. 4. Incorrect: Therapeutic communication is an on going process during any client interaction, particularly when the nurse needs to explain an upcoming procedure. Allowing the client to express fears, verbalize concerns or ask questions enhances cooperation. Although this exchange of information is occurring throughout this period of time, the nurse has another priority action that should be completed first.

Which assessment by the nurse indicates a tension pneumothorax? 1. Sudden hypertension and bradycardia 2. Productive cough with yellow mucus 3. Tracheal deviation and dyspnea 4. Sudden development of profuse hemoptysis and weakness

3. Correct: Yes, as pleural pressure on the affected side increases mediastinal displacement occurs with resultant respiratory and cardiovascular compromise. Symptoms of tension pneumothorax include dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention and cyanosis. 1. Incorrect: Hypoxia causes tachycardia rather than bradycardia. The client would more likely to be hypotensive due to decreased cardiac output. 2. Incorrect: Yellow mucus indicates infection, such as from pneumonia. This does not indicate a tension pneumothorax. 4. Incorrect: Profuse hemoptysis and weakness may indicate a serious condition such as a ruptured vessel, but it is not an indication of a mediastinum shift.

Which clients would the nurse monitor for the development of hypovolemic shock? 1. Having an allergic reaction form multiple wasp stings 2. Post-operative cervical spinal cord surgery 3. Addisonian crisis 4. Partial thickness burns over 50% total body surface area (TBSA) 5. Type 2 diabetic with hyperglycemic hyperosmolar nonketotic coma (HHNK)

3., 4. & 5. Correct: A client in Addisonian crisis loses sodium and water and can have hypovolemic shock. A 10 year old child with 40% burns is shifting fluid to the tissues because of the tissue damage of the burns, increasing permeability. An adult with type 2 diabetes and an infection can develop HHNK. This massive polyuria can cause shock. With polyuria, think shock first. 1. Incorrect: I would worry about anaphylactic shock with this client. 2. Incorrect: I would worry about neurogenic shock with this client.

The nurse is assessing an adolescent newly diagnosed with obsessive compulsive disorder (OCD). The client is nervously rearranging papers on the desk and stating "why can't I stop this?" What would be the most therapeutic response(s) by the nurse at this time? 1. "We can help you control impulses, but you will never be cured." 2. "You will feel much better after beginning your family therapy." 3. "Tell me what part of your disorder you find the most difficult." 4. "You seem nervous and upset about rearranging those papers." 5. "The goal of behavior control can be accomplished with help."

3., 4., & 5. CORRECT: The key in the nurse/client relationship is that interaction must be therapeutic and open-ended to encourage the client to share feelings in a nonthreatening environment. The nurse is asking the client to provide some details about living with the disorder by using a broad opening statement about the challenges of the disorder. Then the nurse is reflecting the client's behavior, indicating a perceived sense of anxiety or being upset. Finally, the nurse is addressing the client's verbalized concerns by stating the probable success of the main treatment goal, thus encouraging the client. 1. INCORRECT: Though there is truth behind this statement, such a negative comment does not provide any hope or comfort to the client. The information is presented in a non-therapeutic manner. 2. INCORRECT: There is often a component of psychotherapy, or "talk therapy" involved in the treatment of OCD. However, this disorder does not require family therapy, but rather individual analysis to help the client understand or control anxiety.

What should the nurse include in the plan of care for a child who is receiving chemotherapy for a diagnosis of leukemia? 1. Place the child in a negative pressure isolation room. 2. Administer prophylactic intravenous (IV) antibiotics. 3. Avoid high protein food intake. 4. Teach family and visitors handwashing techniques.

4. Correct: Any client on chemotherapy should have good infection control measures in place such as handwashing by all who they encounter. 1. Incorrect: If the client is immune suppressed, place them in a positive pressure isolation room. A negative pressure room primarily keeps its air inside the room with controlled venting only; whereas a positive pressure room keeps unfiltered air from outside the room out of the room all together. In a hospital, clients with communicable diseases, especially airborne ones, are kept in isolation rooms. In order to ensure the safety of other clients, staff and visitors, it is important that the isolation room contain negative air pressure. This will keep any germs from entering the general airflow and infecting other people. Positive pressure isolation rooms are designed to keep a vulnerable client in isolation safe from contamination from the outside. The air pressure in the room is greater than that outside of it, so it pushes potential infection agents or chemicals away from the client. The most common application is in rooms for client who have compromised immune systems. For these individuals, it is important that no common pathogens, even those that are harmless to healthy people, enter the room. For positive pressure isolation rooms, an anteroom is recommended and incoming air is filtered through both HEPA filters and ultraviolet germicidal irradiation systems, which kill bacteria by exposing them to ultraviolet light. 2. Incorrect: This would be appropriate if there was evidence of a bacterial infection. Just because chemotherapy is being administered does not mean the client has an infection. 3. Incorrect: This client would likely need a high protein diet to meet the nutritional demands of the body during chemotherapy. We need protein for growth, to repair body tissue, and to keep our immune systems healthy. When the body doesn't get enough protein, it might break down muscle for the fuel it needs. This makes it take longer to recover from illness and can lower resistance to infection. People with cancer often need more protein than usual. After surgery, chemotherapy, or radiation therapy, extra protein is usually needed to heal tissues and help fight infection.

The charge nurse is orienting a new nurse to the pediatric unit. Which teaching related to assessment is appropriate? 1. One assessment should be done daily on each client by the charge nurse. 2. An assessment should be done daily on each client at the beginning of the shift. 3. Assessments of clients should be updated as the nurse provides care to clients. 4. Assessments of clients should be done at the beginning of the shift and updated as nursing care is provided.

4. Correct: Assessment is ongoing; however, for each shift a baseline assessment should be done so the nurse can verify or make judgment regarding other findings throughout the 24 hour day. It is best to get the baseline as soon as possible once the shift begins, and update or reevaluate during the shift. This option actually incorporates the other 3 options making it the correct option. 1. Incorrect: Must include ongoing updated assessments, not just one assessment. These can be done by the assigned RN, not the charge nurse. 2. Incorrect: Must include ongoing updated assessments, not just at beginning of shift. 3. Incorrect: Must include initial beginning of shift assessment.

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur into the hip socket correctly. This is accomplished with 90 degrees of hip flexion. 1. Incorrect: Fifteen degrees of flexion is not adequate to keep the femur end in the hip socket. 2. Incorrect: Thirty degrees of flexion is not adequate to keep the femur end in the hip socket. 3. Incorrect: Forty-five degrees of flexion is not adequate to keep the femur end in the hip socket.

An unlicensed assistive personal (UAP) has been floated to the emergency department (ED) because of several staff call offs. Since the UAP has never worked in the ED, what is the most appropriate task the charge nurse could assign? 1. Clean and restock exam rooms after client discharge. 2. Follow another UAP who has worked there previously. 3. Sit at the reception desk and answer incoming calls. 4. Escort clients from the ED to other areas for tests.

4. Correct: Clients seen in the emergency room are often taken to other hospital departments for tests such as X-rays, Cat scans or MRI's. If ordered to another department for testing, such clients are generally stable and could therefore be transported by unlicensed assistive personnel. This is a task UAP's often do on other hospital floors and would be an appropriate assignment. 1. Incorrect: Having never worked the emergency department before, this UAP would not be aware of even basic exam room requirements, particularly involving specialized equipment. Because supplies must be readily available in critical situations, personnel familiar with those requirements and provisions needed for each room should complete restocking of the rooms. 2. Incorrect: A thorough orientation for this UAP would be ideal, especially if there is a chance of being floated to the emergency room again. However, doing so during a staffing crisis is neither appropriate nor efficient, since the UAP is being utilized out of a desperate need for adequate staffing. 3. Incorrect: The reception area personnel are the first staff that encounter incoming clients. This position usually requires some type of training with interviewing techniques or how to determine an acute situation requiring immediate triage. Even answering the phone would involve understanding the necessary prerequisites for that position. This is not an appropriate task for the UAP.

What information should the nurse include in teaching an oncology client the purpose of taking epoetin? 1. Emergency treatment of anemia. 2. Improves quality of life. 3. Used for the prevention of pure red cell aplasia (PRCA). 4. Decreases the need for transfusion.

4. Correct: Epoetin is prescribed to treat a lower than normal number of red blood cells (anemia) caused by chronic kidney disease in clients on dialysis, in HIV clients receiving zidovudine and in cancer clients receiving chemotherapy that develop anemia. Epoetin stimulates the bone marrow to produce more RBCs. 1. Incorrect: Epoetin does not work raoidly enough to be used for the emergency treatment of anemia (RBC transfusion). 2. Incorrect: Epoetin has not been proven to improve quality of life, fatigue, or sense of well-being in clients with cancer. 3. Incorrect: Pure red cell aplasia (PRCA) is a type of anemia that starts after treatment with epoetin or other erythropoetin medications.

A client arrives at the emergency room with 20% partial thickness burns to bilateral lower extremities following a grass fire. Prior to the arrival of the ambulance, friends had soaked the client's legs in cold water for pain relief. The client is now requesting more cold water on legs because of intense pain. What statement by the nurse would be most accurate? 1. "I can soak some towels in water to place on your legs." 2. "I will call the doctor to ask for an order to use wet gauze." 3. "I need to finish my nursing assessment first before treatment." 4. "I must cover your legs with dry gauze to prevent complications."

4. Correct: Initial burn interventions involve stopping the burning process. In order to do so, the burned area should be submerged in cool (not cold) water for ten to fifteen minutes. Any longer may subject the client to hypothermia as well as allowing bacteria to enter the damaged tissue. Therefore, after the initial cooling period, the burn must be covered with dry sterile gauze to prevent further complications. 1. Incorrect: Towels are not sterile and would be inappropriate for a fresh burn. Wet towels would also be too heavy on damaged tissue, may stick to the sloughing skin and moist cloth is not suitable for post-burn care. 2. Incorrect: Wet dressings are not the correct treatment for fresh burns, with or without an order from the healthcare provider. Moisture after the initial cooling period can cause complications. 3. Incorrect: While this statement by the nurse is correct, it does not address the client's request. The nursing process requires all of the assessment to be completed prior to any intervention (except for an airway emergency). Despite the accuracy of the statement, the nurse has not responded to the client's need.

What action is most important for the nurse to take when a client receiving a cephalosporin develops abdominal cramping and diarrhea? 1. Administer antidiarrheal medication. 2. Increase fluid intake. 3. Provide food with the medication. 4. Notify the healthcare provider.

4. Correct: Notify the healthcare provider if diarrhea occurs as it can promote the development of Clostridium difficile infection. Cephalosporin difficile is a toxin producing bacteria that causes antibiotics-associated colitis, and can occur with antibiotic therapy. Cephalosporin is one of the most common antibiotics that cause clostridium difficile. 1. Incorrect: Taking a probiotic, stopping the antibiotic or switching to another antibiotic are standard treatments for antibiotic induced diarrhea. Administering an anti-diarrheal is not recommended for antibiotic induced diarrhea. 2. Incorrect: Increasing fluid intake will help with the associated dehydration seen with diarrhea, but will not correct the problem or decrease the risk of clostridium difficile. 3. Incorrect: If the client has GI upset, then cephalosporin may be given with food, however, the most important thing to worry about is the development of Clostridium difficile infection. So notifying the healthcare provider is the most important action.

The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find? 1. Increased white blood cells 2. Presence of protein 3. Presence of ketones 4. Increased specific gravity

4. Correct: Specific gravity is an indicator of hydration status and urine osmolality. In a dehydrated client, specific gravity is increased, indicating highly concentrated urine. 1. Incorrect: White blood cells should not be found in the urine unless an infection is present. Dehydration does not cause white blood cells in the urine. 2. Incorrect: Protein should not be found. Presence of protein indicates renal disease. In order to have proteinuria there must be damage to the glomeruli 3. Incorrect: Ketones should not be present. They are found in clients with poorly controlled diabetes or hyperglycemia, because ketones are a by-product of fat breakdown. Fats are broken down and used for energy when glucose cannot be transported into the cells because of lack of insulin.

A nurse is caring for a client who has been prescribed sucralfate. Which client education intervention would the nurse include for the client prescribed sucralfate? 1. Take medication 1 hour after meals. 2. Crush tablets prior to taking medication. 3. Consume 1000 mL of fluid every 24 hours. 4. Avoid antacids 1 hour before and after this medication

4. Correct: Sucralfate is absorbed more effectively in an acidic state. Since an antacid medication will increase the alkaline state, the client should avoid taking antacids within 1 hour before or after taking sucralfate to increase the absorption rate of sucralfate. 1. Incorrect: Sucralfate should not be taken 1 hour after a meal. To increase the absorption of sucralfate the medication should be taken on an empty stomach when the stomach is more acidic. 2. Incorrect: Clients should not crush, or chew sucralfate tablets. The outer layer of the tablet has specific formulated pharmacokinetic properties that should not be crushed or chewed. 3. Incorrect: A potential side effect of sucralfate is constipation. An increase of fluids during the medication therapy is recommended to decrease the side effect of constipation. An intake of 1000 mL of fluid per 24 hours intervention is not enough fluid to reduce the possibility of constipation.

A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would require an immediate intervention? 1. The nasogastric (NG) tube contents are pale green. 2. An abdominal dressing with the tape on 3 sides of the dressing. 3. Abdominal pain of 5 on 10 point pain scale when client coughs. 4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.

4. Correct: The JP drain should be addressed first. The purpose of the JP drain is to remove fluids adjunct to the surgical site by suction. The JP bulb should be continually compressed to create suction in the tube which will remove fluid. The compression of the bulb is released when the fluid in the bulb is emptied and then recompressed. 1. Incorrect: The description of the contents in the NG tube are green. This is indicative of a normal finding of stomach contents. The gastric contents are usually cloudy and green. 2. Incorrect: The question does not indicate any drainage occurring along the side that is not taped. Taping the dressing on all four sides is not the immediate nursing intervention. 3. Incorrect: When the client coughs, the abdominal muscles contract. The resulting movement of the incision site will result in the client experiencing pain. The client's pain should be addressed, but this is not the immediate nursing intervention.

A psychiatric client tells the day shift nurse, "The night nurses have been stealing from all of us while we are sleeping." What is the nurse's best response? 1. "Can you prove what the nurses are stealing?" 2. "No nurse working here would steal." 3. "You must have misunderstood what you were seeing." 4. "Tell me more about what you saw."

4. Correct: This open ended question allows for exploring the idea the client has. This statement does not accuse anyone or deny the possibility of stealing. This statement allows the nurse to remain nonthreatening and nonjudgmental. 1. Incorrect: This response shows disapproval. This statement could make the client feel uncomfortable and seem like the nurse is taking the side of the other nurses. 2. Incorrect: This response is disagreeing with the client. This is a closed-ended statement that does not allow the client to discuss this topic further. Since the nurse has said no nurse would steal then the client most likely will become defensive. 3. Incorrect: This response is defending. It also makes the client feel that the nurse does not believe them.

During night time rounds, the nurse finds a client has cigarettes in bed and the room is filled with smoke. In what order should the nurse perform the following actions? Pull the fire alarm handle. Notify hospital operator. Close the client's door. Remove client from room. Get the fire extinguisher.

Anytime an internal disaster is suspected, client safety is always the first concern. National Fire Safety codes refer to the pneumonic "R-A-C-E" (rescue -alarm-contain-extinguish). If the area is safe for the nurse to enter, removing the client from that environment would be the first action. Secondly the nurse must activate the EMS alarm system so that emergency personnel are en route. Additionally, the hospital must be alerted by contacting the hospital operator to activate appropriate internal alarm systems. Closing the client's door will help contain any fire or smoke. Finally, the nurse should obtain the closest fire extinguisher appropriate for the type of fire.

In what order will the nurse provide instructions to a client on using a cane? With cane on stronger side of body, support body weight with both legs. Move cane forward 6-10 inches (15 - 25 cm). Advance weaker leg forward toward the cane. Advance stronger leg forward toward cane.

First, with cane on stronger side of body, support body weight with both legs. This will support the even distribution of weight away from the weaker side to promote a normal gait. Second, move cane forward 6-10 inches (15-25 cm). Moving the cane the approximate distance of a normal gait helps with stability. Third, advance weaker leg forward toward the cane. This allows the weight to be supported by the cane and the stronger leg. Fourth, advance stronger leg forward toward the cane. This allows the weight to be supported by the can and weaker leg.