Fundamentals ATI Dynamic Quiz chapters 6,7,9,12,26,35,41

Ch 9 - A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound." Explanation - The home health nurse will provide wound care as prescribed and educate the client about wound care and illness management.

Ch 9 - A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

"I'll wear non sterile gloves." Explanation- Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribes sterile gloves for dressing changes.

Ch 35 - A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress?

"God is punishing me for something." Explanation- Spiritual distress is an impaired ability to integrate meaning and purpose in life through various means, including belief systems and relationships. Manifestations of spiritual distress can include a feeling that a higher power is punishing the individual for some behavior.

Ch 41 - A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"If I do this often, I won't get pneumonia." Explanation - Turning, coughing, and breathing deeply help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal.

Ch 41 - A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse." Explanation - The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief.

Ch 41 - After a disaster plan is enacted, a nurse in a pediatric unit is asked to prepare a list of clients who can be discharged home due to a local incident involving many children. Which of the following clients should the nurse place on the potential discharge list? (Select all that apply.)

- A preschooler with asthma who has scattered wheezes that resolve with PRN albuterol - A school-age child with a femur fracture in an external fixation device whose pain is controlled with PRN oral codeine - An adolescent client who is developmentally delayed, has a PICC line, and needs 6 more weeks of antibiotics Explanation - The nurse should place clients who can be quickly and safely discharged on the potential discharge list. Children who have asthma can be managed at home once the acute phase of illness has resolved. Because the preschool client's manifestations are responsive to the prescribed medication, this child can be safely discharged home with appropriate discharge teaching and follow-up care planning. External fixation devices are worn for weeks to months; they are often managed at home once the device is placed and the client has learned how to care for the immobilized limb. This school-age client's pain is responsive to oral codeine. Prior to discharge, the client might need instructions on ambulation and weight-bearing, as prescribed. Long-term antibiotic therapy is typically completed in the home following PICC line placement. A visiting nurse can assist this adolescent client with home care management. The client's developntental delay has no bearing on whether the client is safe to discharge.

Ch 12 - A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask Explanation - The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

Ch 12 - A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first?

Accompany the client back to his room Explanation - The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect him from injury due to wandering.

Ch 26 - A nurse in a provider's office is documenting the results of a general survey of a client who is new to the practice. The client reports an inability to find pleasure in any activities she previously enjoyed. Which of the following terms should the nurse use to describe the client's mood?

Anhedonia Explanation- Anhedonia is an inability to experience pleasure. This finding is especially concerning when the client no longer enjoys the activities that once produced pleasure.

Ch 41 - A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication Explanation - Using the nursing process, the nurse should first assess the reason for the client's refusal of the opioid pain medication.

Ch 35 - A nurse is caring for a client who has hearing loss. The nurse should plan which of the following interventions when communicating with the client?

Attract the client's attention before speaking

Ch 9 - A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

Client's level of comfort and ability to participate in the interview Explanation - The nurse should assess the client's level of comfort and establish a rapport during the introductory or orientation phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation. This will assist the nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.

Ch 41 - A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching?

Clients who are age 65 or older are reluctant to report pain. Explanation - The nurse should instruct the newly licensed nurse that clients age 65 and older frequently can be reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected.

Ch 12 - A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing Explanation- The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound increases the risk of peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

Ch 7 - A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits Explanations - When using the nursing process, the nurse should first assess the client's readiness to commit to a change in behavior.

Ch 26 - A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe Explanation - Caring for this client requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision.

Ch 7 - A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe Explanation - Caring for this client requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision.

Ch 9 - A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning?

During the admission process Explanation - The nurse should initiate discharge planning as soon as the client is admitted to the facility. This is intended to ensure the continuity of care and meet the client's care needs. This process should include each member of the client's health care team.

Ch 41 - A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?

Encourage the client to listen to soft music Explanation - The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain.

Ch 9 - A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform?

Hold the linens away from the body and clothing Explanation- The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms.

Ch 9 - A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?

Inspect both breasts simultaneously Explanation - According to evidence-based practice, the nurse should first inspect both breasts with the client's arms in several different positions to look for asymmetry, masses, retraction, lesions, inflammation, and dimpling.

Ch 9 - A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?

Intraoperative Explanation - Intraoperative care begins when the client is transferred to the surgical suite table and ends when the client is admitted to the PACU.

Ch 9 - A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique?

Keeping microorganisms from entering the wound Explanation - Starting at the area of least contamination and working toward the area of greatest contamination prevents the spread of microorganisms within the wound.

Ch 9 - A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher. Explanation- Locking the wheels prevents the client from falling on the floor by not allowing the cart or bed to move apart or away from the client.

Ch 12 - A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor Explanation - The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect the client from injury.

Ch 7 - A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

Obtain client information Explanation -The nursing process is based on the scientific process. The first step in the scientific process is collecting data. Therefore, the first step in the nursing process is assessing and obtaining information about the client.

Ch 9 - A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter. Explanation - Federal mandates require that a professional medical interpreter translate the client's health care information into the client's native language.

Ch 35 - A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event?

Paralysis of a client's lower extremities occurred following epidural anesthesia. Explanation - An incident resulting in permanent harm, such as paralysis or death, is a sentinel event. Sentinel events are a high priority and indicate the need for an immediate investigation.

Ch 12 - A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests?

Romberg Explanation- A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could fall during this test.

Ch 35 - A nurse working in a mental health facility is preparing to discharge a client who has schizophrenia and requires assistance with housing. Which of the following referrals should the nurse recommend to the provider?

Social worker Explanation - The nurse should identify that a social worker assists clients with issues such as finances, day-to-day concerns, and suitable housing options.

Ch 35 - A nurse is planning care for a client who has COPD, requires continuous oxygen therapy, and is being discharged to return home. Which of the following referrals should the nurse recommend?

Social worker Explanation- The nurse should recommend a referral to a social worker when a client will require additional services, such as home health care, oxygen therapy, hospice care, or wound care.

Ch 6 - A nurse is working with an assistive personnel (AP) in a long-term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks?

The degree of supervision that the AP will require to complete the task Explanation- Successful delegation involves assigning the right task to the right person under the right circumstances. The person who will perform the task must be given adequate direction and specification regarding the amount of supervision that will be provided. The right communication of expectations and the right feedback about performance must also be supplied.

Ch 35 - A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures. Explanation - A client may define and react to disease based on his or her unique cultural perspective. The nurse should seek to understand a client's culture and life experiences in order to provide care that is effective, evidence-based, and culturally congruent.

Ch 9 - A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?

Wear cotton clothing to avoid static electricity. Explanation- The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.

Ch 41 - A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PA button." Explanation - The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA pump to reduce the amount of opioid dosing the client needs.

Ch 12 - A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PA button." Explanation - The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA pump to reduce the amount of opioid dosing the client needs.

Ch 12 - A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first?

"I can't sleep well because whenever I move in my sleep, the pain wakes me up." Explanation - The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort. The nurse should re-evaluate the client's pain management plan immediately.

Ch 41 - A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first?

"I can't sleep well because whenever I move in my sleep, the pain wakes me up." Explanation - The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort. The nurse should re-evaluate the client's pain management plan immediately.

Ch 12 - A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?

"I will put a night-light in the hallway." Explanation - The nurse should instruct the client to use night-lights in and around the home as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to see surroundings. Older adults and infants are at an increased risk of serious injury from falls, and most falls occur in the client's home.

Ch 9 - A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?

"I will put a night-light in the hallway." Explanation - The nurse should instruct the client to use night-lights in and around the home as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to see surroundings. Older adults and infants are at an increased risk of serious injury from falls, and most falls occur in the client's home.

Ch 41 - A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one." Explanation - It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressings.

Ch 9 - A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one." Explanation - It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressings.

Ch 41 - A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse." Explanation - The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief.

Ch 9 - A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying?

"It sounds like your pain is intermittent." Explanation - This response by the nurse reflects the communication technique of clarifying. The nurse should use this technique to ensure an understanding of the client's message.

Ch 9 - A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

"Keep the rubber crutch tips securely in place." Explanation - The client should never use crutches without the rubber crutch tips. The client should inspect the tips regularly, replace them when they show signs of wear, and remove and dry them thoroughly with paper towels if they become wet.

Ch 35 - A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?

"The dietitian will help you choose foods you are used to that also meet your health needs." Explanation - This response shows respect for the client's food preferences and cultural needs by offering choices from among the client's usual foods.

Ch 9 - A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?

"The dietitian will help you choose foods you are used to that also meet your health needs." Explanation - This response shows respect for the client's food preferences and cultural needs by offering choices from among the client's usual foods.

Ch 35 - A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask?

"What is your source of strength and hope?" Explanation- This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse's part. It correctly focuses on a global view of spirituality as a complex concept that encompasses the client's life experiences and beliefs about strength, love, and hope.

Ch 9 - A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.)

- Place the client in a supine position with the hips and knees flexed - Cover the wound and intestine with a sterile, moistened dressing - Monitor the client for manifestations of shock Explanation - The nurse should place the client in a supine position with the hips and knees flexed. This position can help to prevent further tearing of the incision and wound evisceration by lessening tension on the wound. The nurse should cover the protruding intestine with a sterile dressing that is moistened with 0.9% sodium chloride to prevent further contamination of the wound and to keep the protruding intestine from drying out. The nurse should monitor the client for a physiological stimulus (e.g. bleeding from the tearing or opening of the wound) or a psychological stimulus (e.g. viewing the intestine protruding outside of the body), which can increase the risk of shock. The nurse should monitor the client for increased heart rate and respiratory rate, changes in blood pressure or mentation, and cool or clammy skin.

Ch 26 - A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene Explanation - The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered.

Ch 7 - A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene Explanation - The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered.

Ch 9 - A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies Explanation - The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals.

Ch 7 - A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies Explanation - The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals.

Ch 26 - A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies Explanation- The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals.

Ch 7 - A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication Explanation - Using the nursing process, the nurse should first assess the reason for the client's refusal of the opioid pain medication.

Ch 12 - A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first?

Assess the client. Explanation - The greatest risk to the client's safety is adverse effects from either receiving the wrong medication or not receiving the prescribed medication. The nurse should assess the client first for any possible adverse effects. This assessment also serves as a baseline for further monitoring for adverse effects.

Ch 7 - A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

Assessment Explanation - Collecting this data is included in the assessment portion of the nursing process. In addition, the nurse should explore the client's health history and perform a physical examination.

Ch 26 - A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assessment Explanation - When caring for a client, the nurse should apply the nursing process priority-setting framework. The nursing process is used to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision.

Ch 7 - A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assessment Explanation - When caring for a client, the nurse should apply the nursing process priority-setting framework. The nursing process is used to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision.

Ch 9 - A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

Assigning another client with the same infection to share the room with the client Explanation - The nurse can place clients who are infected with the same pathogen in the same room if a private room is not available.

Ch 12 - A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take?

Assist the client in finding local smoking-cessation assistance programs Explanation - Smoking cessation slows the progression of chronic obstructive pulmonary disease (COPD). It is not "too late" for this client to stop smoking, and the nurse should encourage the client to do so.

Ch 7 - A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?

Check the client for Injuries Explanation - Using the nursing process, the nurse should first evaluate the client for any injuries or physiological changes. The nurse should also notify the provider to determine the need for any further examination or intervention.

Ch 7 - A nurse is caring for a client who has a stage Ill pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level Explanation - The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should determine the client's level of pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the client approximately 30 minutes prior to wound care will decrease pain and increase comfort.

Ch 26 - A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level Explanation- The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should determine the client's level of pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the client approximately 30 minutes prior to wound care will decrease pain and increase comfort.

Ch 26 - A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum Explanation - The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.

Ch 7 - A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum Explanation - The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.

Ch 9 - A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer?

Check the client's vital signs Explanation - The greatest risk to this client is an injury from unstable vital signs (e.g. hypotension and respiratory depression) after receiving anesthesia and medication. Therefore, the first action the nurse should take is to check the client's vital signs and compare them with the readings during the PACU stay.

Ch 12 - A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked Explanation - The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. This approach reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Hence, the first action the nurse should take is to inspect the tubing carefully, straighten any kinks, and ensure there are no dependent loops. A lack of drainage is often due to a kink in the tubing or the client lying on it.

Ch 7 - A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness. Explanation - The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

Ch 26 - A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness. Explanation- The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

Ch 12 - A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?

Cotton wisps Explanation - The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth.

Ch 12 - A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 min. Explanation - If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.

Ch 7 - A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

Establish client outcomes. Explanation - The planning phase of the nursing process includes developing goals and outcomes that help[the nurse create the client's plan of care.

Ch 12 - A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility?

Evacuate clients from the unit Explanation - The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk during a fire is injury to clients; therefore, the nurse's priority action is to evacuate clients from the unit. The nurse should follow the RACE protocol when responding to a fire: rescue, activate, confine, and extinguish.

Ch 12 - A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first?

Evacuate the client from the room. Explanation - The acronym RACE can help nurses remember the order of the actions to take in the event of a fire. The components of RACE are rescue, activate, confine, and extinguish. The first priority is rescuing or removing the client from immediate danger. The second action is activation of the fire alarm system. The third action is confining the fire by closing doors and windows. The final action is extinguishing the fire, if possible, using an available fire extinguisher. If attempts to extinguish a fire could compromise the safety of clients or staff members, the nurse should await the arrival of emergency fire personnel.

Ch 12 - A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses Explanation - For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

Ch 12 - A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client Explanation - The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Informing the client about the procedure reduces fear and assists in gaining the client's cooperation, which is important for NG tube insertion and is the priority nursing intervention.

Ch 12 - A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using 2 identifiers. Explanation- The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can proceed with the other options. This action is the priority because it provides for the safety of the client. The nurse must be certain that each client receives only what has been prescribed.

Ch 9 - A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

Locking the brakes on the bed and the wheelchair before moving the client Explanation- Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair.

Ch 7 - A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority?

Measure the client's apical pulse Explanation - The first action the nurse should take using the nursing process is to assess the client by measuring the client's apical pulse. Atenolol is a beta blocker and can decrease the client's heart rate.

Ch 7 - A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

Measure the client's apical pulse rate Explanation - The first action the nurse should take using the nursing process is to assess or collect data from the client. This pulse rate is below the expected reference range for an adult. The nurse and a coworker should measure the apical and radial pulse rates simultaneously to determine if there is a pulse deficit. If the client's radial pulse rate is lower than the apical rate, the client might have a cardiovascular disorder.

Ch 12 - A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps Explanation- The nurse should apply the least-restrictive priority-setting framework, which assigns priority to nursing interventions that are the least restrictive to the client, as long as thee interventions do not jeopardize client safety. Least-restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff members, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation of the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replaced, and the ties are secured again without removing the adhesive strips.

Ch 26 - A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations Explanation - The nurse should apply the nursing process priority-setting framework when caring for this client in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision; therefore, the nurse should first assess the client's respiratory status.

Ch 7 - A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations Explanation - The nurse should apply the nursing process priority-setting framework when caring for this client in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision; therefore, the nurse should first assess the client's respiratory status.

Ch 12 - A home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take?

Place the syringe in a puncture-proof disposal container. Explanation - The nurse should place the uncapped syringe in a puncture-proof sharps disposal or rigid plastic container to prevent a needlestick injury. The nurse should keep the syringe uncapped to prevent a needlestick injury while placing the cap on the needle. Then, the nurse should provide client education on safety and proper disposal of syringes.

Ch 9 - A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45-degree angle to the bed. Explanation - Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount of rotation required.

Ch 41 - A nurse is tracking the outcomes of clients on the unit who have received postoperative pain management. This activity demonstrates which of the following competencies of the Quality and Safety Education for Nurses (QSEN) initiative?

Quality improvement Explanation - This QSEN competency involves using data to track outcomes with the goal of devising processes to improve clients' outcomes.

Ch 12 - A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher. Explanation - Evidence-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to perform first.

Ch 6 - A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

Right communication Explanation- The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations.

Ch 12 - A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions Explanation - The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should perform cardiopulmonary resuscitation, which starts with chest compressions followed by opening the airway and breathing for adults and pediatric clients; evidence indicates a great survival rate when chest compressions are started before a breath is initiated.

Ch 9 - A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take?

Talk with the AP about the technique used Explanation - The nurse who delegates a task is responsible for providing the right supervision and evaluation. The nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP, which includes wearing gloves.

Ch 12 - A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature Explanation- Elevated temperature is an emergent physiological need that requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The levels are as follows: physiological needs, safety, and security needs, love and belonging needs, personal achievement and self-esteem needs, and achievement of full potential and the ability to problem-solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first before following the remaining four levels.

Ch 9 - A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility Explanation - The nurse should begin discharge planning at the time that the client is admitted to the facility.

Ch 9 - A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility Explanation - The nurse should begin discharge planning at the time that the client is admitted to the facility.

Ch 41 - A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level Explanation - The nurse should consider Maslow's hierarchy of needs, which includes 5 levels of priority. The levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential and the ability to problem-solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first and then address the client's needs by following the remaining hierarchal levels. The nurse should also consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. To meet the client's physiological needs, the nurse should begin pain management by asking the client to describe her pain.

Ch 12 - A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level Explanation- The nurse should consider Maslow's hierarchy of needs, which includes 5 levels of priority. The levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential and the ability to problem-solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first and then address the client's needs by following the remaining hierarchal levels. The nurse should also consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. To meet the client's physiological needs, the nurse should begin pain management by asking the client to describe her pain.

Ch 41 - A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?

Warm the irrigating solution to 37°C (98.6°F) Explanation - The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature to minimize discomfort and vascular constriction.

Ch 9 - A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Washing dishes Explanation - Washing dishes requires a low level of activity and is appropriate for this client.