Fundamentals Review

The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains that an intrauterine device (IUD) is most appropriate for what individuals? Select all that apply 1. A mother of a toddler who wants another child in three years. 2. The client with a recent exacerbation of sickle cell anemia. 3. A client with stage II breast cancer who has finished chemotherapy. 4. An adolescent who has recently become sexually active. 5. The client with a double mastectomy seven years ago.

1 & 5. CORRECT: An IUD is a surgically placed method of birth control in which a small, t-shaped piece of plastic, or even copper, is inserted into the uterus to decrease the chance of pregnancy. The client must be very healthy, emotionally amenable to a foreign body to prevent pregnancy, and aware that an IUD is not 100% fail-proof. The mother of a toddler who would like to have another child in a few years is an excellent candidate for the use of an IUD. Also, a client who had a double mastectomy over seven years ago is a good candidate, since treatment that long ago means the client would no longer be receiving any type of immunosuppressant therapy. 2. INCORRECT: A client who has had a recent exacerbation of sickle cell anemia is at high risk for several complications, including infection and clots. This is a foreign body in an already compromised client, leading to many potential complications. The potential for blood clots, organ damage, or bleeding following an exacerbation is also too great to consider using an IUD. 3. INCORRECT: This client is immunocompromised, having just completed a round of chemotherapy. The type of birth control chosen for this client must involve the oncologist and a determination of what factors are safer. This client is at high risk for infection, particularly with an implanted foreign body. 4. INCORRECT: An adolescent who has recently become sexually active presents a challenge. Remember that an adolescent does not have regular menstrual cycles yet, and can experience intermittent bleeding. Many primary healthcare providers argue that the use of an IUD may be safer since the client would not have to remember a pill, a ring, or a patch. But an even greater concern is the fact that an IUD is NOT 100% effective, still presenting the risk of an unwanted pregnancy. Also, an IUD does not protect against sexually transmitted disease (STDs), which is often a concern in those who have become sexually active.

Which nursing statements about a client reflect correct documentation in the hospital medical record? Select all that apply 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.

1. & 2. Correct: The nurse should record findings or observations precisely and accurately. Percent of breakfast eaten is accurate documentation. An arm wound should include its exact size and location. 3. Incorrect: Documentation of enema administered should also include type of solution, amount and results. 4. Incorrect: Documenting observed behaviors or conversations is appropriate; however, drawing conclusions about feelings is not. A better notation would be to describe facial expression and any emotions exhibited,( i.e. crying, laughing, etc.). 5. Incorrect: This documentation does not give body position and does not provide pertinent information about the position of bed and side rails or light placement.

A client at 31 weeks gestation is being seen by the primary healthcare provider for reports of generalized illness. When assessing the client, the nurse would immediately report what symptom to the primary health care provider? 1. Right upper quadrant pain 2. Nausea with vomiting 3. Severe headache 4. Blurred vision

1. CORRECT: The symptoms being reported by the client indicates hemolysis of blood cells, elevated liver enzymes and low platelet count (HELLP) Syndrome, a life-threatening liver disorder related to preeclampsia. Occurring generally in the third trimester, or even right after birth, the exact cause is unknown. The only treatment is to deliver the fetus. All the reported symptoms are concerning, but right upper quadrant pain indicates problems with the liver. Enlargement of the liver causes the liver capsule to stretch, leading to pain. Sometimes the client will also report that the pain is extending into the shoulder or neck. This symptom indicates the client is in a life-threatening situation, with the only treatment being to deliver the fetus. In most instances, the client can deliver vaginally. A cesarean section is not always needed. The nurse needs to contact the primary healthcare provider immediately to prevent maternal death. 2. INCORRECT: Nausea and vomiting are generally complaints reported early in the first trimester. The return of these symptoms could indicate a general illness and would need to be investigated. However, nausea and vomiting is not the greatest concern with this client. 3. INCORRECT: A severe headache would lead the nurse to investigate blood pressure, as preeclampsia could cause elevated blood pressure. However, this is not the most serious reported symptom by the client. 4. INCORRECT: Blurred vision is definitely alarming and should be reported to the primary healthcare provider by the nurse. Combined with a severe headache, the nurse will need to report these findings. But there is another finding that is more urgent to report.

A night nurse is receiving report from the day nurse when the day nurse states, "I have an appointment and I need to leave. Can you get the rest of the client's information from the medical records?" What client right may be compromised by the day nurse's request? 1. Reasonable continuity of care 2. Confidentiality 3. Considerate and respectful care 4. Participation in decision making

1. Correct: An incomplete or uninformative client report from one healthcare provider to the next may compromise the client's right to reasonable continuity of care. The properly done hand-off report shares essential information and helps to provide client safety and continuity of care. The oncoming nurse needs an opportunity to clarify information from the outgoing nurse. 2. Incorrect: The client's right to confidentiality is not violated because both nurses have been assigned to care for the client. Information pertaining to client care is passed between healthcare providers during care reports to safeguard continuity of care. 3. Incorrect: The right to considerate and respectful care is not addressed in this scenario. 4. Incorrect: The right to make decisions about the plan of care is not addressed in this scenario.

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. Remove the client from the room immediately. 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed assistive personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit.

1. Correct: Rescue/Remove the client; first step in Rescue, Alarm, Contain, Extinguish (RACE). 2. Incorrect: Never leave the client in an unsafe environment. Remove the client from the area. 3. Incorrect: Not first action in RACE. Get the client out of the area first. The UAP may need to help you with this. Don't send the UAP away. 4. Incorrect: Not first action in RACE. Remove the client in immediate danger first. All clients may not have to be evacuated if the fire is contained and extinguished.

Which action by a nurse would indicate that this nurse is following standard precautions? 1. Clean gloves while performing a heel stick on an infant. 2. Sterile gloves to empty a indwelling urinary catheter bag. 3. Shoe covers when entering the room of a client with influenza. 4. Clean gloves while inserting a urinary catheter.

1. Correct: Standard precautions when drawing blood is to wear gloves so blood will not get on the nurse's hands. Clean gloves are appropriate. 2. Incorrect: Clean gloves for the nurse's protection are needed. Sterile gloves are not needed as part of standard precautions. 3. Incorrect: Shoe covers are not a standard precaution and not needed when entering the room of a client with influenza. 4. Incorrect: Sterile gloves are needed to insert a urinary catheter. Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all clients. ASSESS THE RISK of exposure to body substances or contaminated surfaces BEFORE any health-care activity. Make this a routine! Select PPE based on the assessment of risk: clean non-sterile gloves, clean, non-sterile fluid-resistant gown, mask and eye protection or a face shield.

The client reports having trouble sleeping at night. "My mind is constantly working, and I can't fall asleep until 2:00 or 3:00 a.m."Which behaviors found in the assessment are likely to contribute to sleep difficulty? Select all that apply 1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. 4. Reads for pleasure before going to bed. 5. Exercises 45 minutes at 5 pm each evening.

1., 2. & 3. Correct: Working on job-related tasks before bedtime may increase anxiety and contribute to difficulty sleeping. Suspenseful night-time drama TV shows may be too stimulating prior to going to bed. Caffeine following dinner may interfere with sleep. 4. Incorrect: Quiet reading is likely to ease the transition from wakefulness to sleep and may be an important intervention to promote sleep. 5. Incorrect: Exercising early in the evening may be an effective intervention. If exercise is performed prior to going to bed, it may interfere with falling asleep.

The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.

1., 2., & 5. Correct: These actions by the new nurse are not done properly. The measurement for tube placement should be nose to ear and then xiphoid process. Lubricate the tube with a water solution, not a petroleum gel. Never place the tube in water because if the tube is in the trachea, the client can aspirate the water into the lungs. 3. Incorrect: This is the proper technique for checking placement of the NG tube. The pH should be less than 5 if in the stomach. 4. Incorrect: Yes, the tubing should be marked with a piece of tape and secured to the nose with tape or a commercial device if available.

The nurse is teaching the family of a homebound client about ways to increase the client's safety while bathing independently. Which strategies should the nurse include? Select all that apply 1. Install grab bars in the tub or shower. 2. Install hand bars on sides of tub. 3. Use tub/shower seat for bathing. 4. Provide a long-handled loofa for bathing. 5. Schedule bathing routines three times per week.

1., 2., 3. & 4. Correct: Grab bars will assist the client in getting into or out of the tub or shower, thus reducing the chance for falls. Hand bars are very helpful as one enters or exits the tub. The increased stability offered by these devices reduces risk of falls. Using a shower seat will allow the client to remain independent in terms of entering or exiting the tub or shower. The use of handled scrubbies or sponges allows the client to reach lower extremities or back with greater ease. 5. Incorrect: The bathing routine may need to be more often than three times per week depending on the client. The bathing schedule does not relate to a client's independence.

A nurse is attempting to help a client who has self-care difficulty due to left sided paralysis. Which interventions should the nurse plan to include? Select all that apply 1. Provide the client with a button hook for dressing 2. Have client comb own hair 3. Offer to take the client to the toilet every 2 hours 4. Identify preferences for personal care items and food 5. Have client pivot on left foot to sit in chair placed on right side parallel to the bed.

1., 2., 3. & 4. Correct: The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity. This is a one handed task that will enable the client to maintain autonomy for as long as possible. Having client comb own hair helps maintain autonomy. Identifying food and personal care item preferences support the client's independence. Offer bedpan or place client on toilet every 2 hours during the day and three times during the night. 5. Incorrect: Have client pivot with the right foot with the chair placed on the left side parallel to the bed. The nurse shouldn't place the chair on right side or perpendicular to the bed because the client won't be able to support his weight on the left leg.

What test should the nurse use to test a client's gross hearing acuity? Select all that apply 1. Weber's 2. Rinne 3. Audiometry 4. Whisper 5. Monofilament testing

1., 2., 3., & 4. Correct: The Weber test uses a tuning fork to assess bone conduction by examining the lateralization of sounds. The Rinne test compares air to bone conduction. Audiometric testing determines the degree and type of hearing loss. The audiometer produces pure tones at varying intensities to which the client can respond. The ticking of a watch has a higher pitch than the normal voice. Have client occlude one ear. Out of the client's sight, place a ticking watch 1 inch (2-3 cm) from the unoccluded ear. Ask what the client can hear. Repeat with the other ear. With the whisper test, the examiner stands 12-24 inches (30-61 cm) to the side of the client and, after exhaling, speaks using a low whisper. The client is asked to repeat numbers or words or answer questions. Each ear is tested. 5. Incorrect: Monofilament testing identifies sensory neuropathy, particularly of the feet.

After determining that a client diagnosed with a stroke has adequate swallowing ability, the nurse develops interventions to safely provide oral feedings to the client. What interventions should the nurse include in this plan of care? Select all that apply 1. Provide mouth care prior to feeding. 2. Flex head forward for eating. 3. Have dietary puree foods. 4. Use crushed ice as a stimulant for swallowing. 5. Offer thickened liquids to drink. 6. Position client in semi fowler's position after feeding.

1., 2., 4., & 5. Correct: These interventions will stimulate sensory awareness, salivation, swallowing, and decrease the risk of aspiration. Mouth care before feeding helps stimulate awareness and salivation. Saliva helps you chew, taste, and swallow. Flexing the head forward bends the cervical spine at its highest point C1 through C2. Head flexion moves the chin against the neck. This type of chin-tuck is used to reduce residual particles of food pocketing in the epiglottic vallecula. Crushed ice can act as a stimulant. Have the client swallow and then swallow again. Thin liquids are often difficult to swallow and many promote coughing. Thin liquids can be thickened with commercially available thickening agents. Avoid milk products because they tend to increase the viscosity of mucous and increase salivation. 3. Incorrect: Pureed foods are not usually the best choice because they are often bland and too smooth making it difficult to swallow. 6. Incorrect: The client should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for feeding and for 30 minutes afterward.

What should the nurse check when assessing a client's balance? Select all that apply 1. Walking on tiptoes 2. Babinski reflex 3. Romberg test 4. Muscle strength of legs 5. Dorsalis pedis pulses

1., 3., & 4. Correct: Asking the client to walk on the tips of the toes assesses foot strength and balance. Muscle strength is needed to maintain balance and a Romberg's test asks the client to stand erect with arms at their side and feet together. The nurse notes any sway or unsteadiness. Then the client does the same thing with their eyes closed for 20 seconds again noting imbalance and sway. A positive Romberg is seen with swaying and moving feet apart to prevent a fall. It indicates a problem with balance. 2. Incorrect: Babinski sign is an important neurologic examination based upon what the big toe does when the sole of the foot is stimulated. If the big toe goes up, that may mean trouble with the central nervous system. This is not part of assessment for balance 5. Incorrect: Assessing the dorsalis pedis pulse is done as part of a circulatory check not while assessing balance.

A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the nurse? Select all that apply 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre-op diazepam 10.0 mg given po 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.

1., 3., & 5. Correct. These are written correctly. The first entry provides the age, provides the diagnosis, room number, and plan for care. this gives a "snap shot" of the admission. Option 3 is documentation of informed consent for surgery. It states that the consent is signed, the surgery to be performed, and very importantly, that the client is consenting to surgery after the surgeon discussed the procedure. Option 5 appropriately documents a transfer. It presents where the client was transferred, how they were transported, and the condition upon their transfer. 2. Incorrect. "Appears" is subjective. Pain should be assessed in an objective manner, such as by using a pain scale. The nurse should not use subjective documentation of the client's pain. 4. Incorrect. Do not use trailing zeros after a decimal point. Always lead a decimal point with a zero (0.5). These are safety issues. Trailing zeros are identified on the Joint Commission on the Accreditation of Hospitals Organization (JCAHO) "Do Not Use" list. The placement of a zero after a decimal point could lead to the inadvertent administration of a medication ten times the prescribed dose if the decimal point was not noted or could not be seen. Nurses should always follow JCAHO standards and guideline for documentation and nursing care.

The nurse is caring for a client that requires lifting. What techniques should the nurse utilize to prevent injury to self and potentially the client? Select all that apply 1. Tighten stomach muscles. 2. Keep the knees straight. 3. Keep weight to be lifted close to body. 4. Bend at the waist. 5. Avoid twisting the body.

1., 3., & 5. Correct: Tightening the stomach muscles provides stability for the movement. Keeping the weight close to the body provides additional support and reduces the risk of a stretching type injury. When the body is in alignment, it is considered to be balanced. Therefore, twisting motions cause the body to be off balanced and make the nurse more susceptible to injury. 2. Incorrect: The trunk should be kept straight, and the knees should be bent. This provides an upright posture to maximize stability and reduce risk of injury. 4. Incorrect: The trunk should be kept straight, and the knees should be bent. This provides an upright posture to maximize stability and reduce risk of injury. Bending at the knees helps prevent back injuries.

After assessing a client, the nurse determines that the client has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which interventions would the nurse include for this client? Select all that apply 1. Encourage intake of cranberry juice daily. 2. Encourage the client to void every 8 hours. 3. Perform Credé method. 4. Pour warm water over perineum. 5. Teach intermittent catheterization for retention, if needed.

1., 3., 4. & 5. Correct: Encourage intake of cranberry juice daily. This keeps urine acidic. Place bedpan, urinal, or bedside commode within reach. Provide privacy. Have client listen to the sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. Perform Credé method over bladder to increase bladder pressure. The Credé method (pressing down over the bladder with the hands) increases bladder pressure, and this may stimulate relaxation of the sphincter to allow voiding. If these methods are unsuccessful, the client will need education on intermittent catheterization. 2. Incorrect: Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create an infection.

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? Select all that apply 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.

1., 3., 4. & 5. Correct: The nurse should ensure that the consent form is signed, the lab work is in order, and any prescribed preoperative medication is given. The operative site is marked by the person who is ultimately accountable for the procedure and will be present when the procedure is performed. 2. Incorrect: The site should be prepped with clippers as opposed to a razor, which can cause injury to the client. The goal of preoperative skin preparation is to decrease bacteria without injuring the skin.

The nurse is reviewing discharge instructions with the spouse of client following a laminectomy. When the nurse explains the need to log roll the client, the spouse expresses doubt about the ability to do so independently. What statement by the nurse is appropriate? 1. "Many spouses have been able to learn this procedure." 2. "Which part of this procedure has you most concerned?" 3. "Don't you have any family to help you with this procedure?" 4. "Are you worried about caring for your spouse?" Laminectomy: A surgical operation to remove the back of one or more vertebrae, usually to give access to the spinal cord or to relieve pressure on nerves.

2. CORRECT. The nurse's question is open-ended since it allows the spouse to elaborate on any specific areas of concern or doubt. This approach encourages the spouse to express feelings with any care after discharge, and not just the log rolling technique. 1. INCORRECT. This statement by the nurse directs attention away from the spouse's expressed concerns, ignoring feelings stated by the spouse. It implies anyone could perform the needed log rolling and is dismissive of the spouse. 3. INCORRECT. Although the nurse may have meant to suggest others could help the spouse, the phrasing of the question insinuates the spouse should seek others to help, whereas the nurse should focus on educating and encouraging the spouse to perform the task independently. 4. INCORRECT. While the spouse's verbalized concerns may be subconsciously connected to overall care of a post-surgical client, the nurse's comment is an assumption and is confrontational.

Staff notifies the nurse that a client receiving tube feedings has increased liquid stool with new rectal excoriation. Following an assessment, the nurse is most concerned about what additional symptom? 1. Reports feeling increasingly tired. 2. Trousseau's sign noted when taking blood pressure. 3. Increased resistance to care activities. 4. Reports abdominal cramping.

2. CORRECT: When a client begins to lose large amounts of stool, important electrolytes such as magnesium are lost also. The presence of Trousseau's sign indicates the client has developed hypomagnesemia and is at risk for more serious problems. The nurse should notify the primary healthcare provider immediately. 1. INCORRECT: The client has many health issues which could contribute to fatigue, including hospitalization, illness and tube feedings. Dehydration secondary to the feedings could increase fatigue and the nurse will need to investigate further. However, another symptom is more concerning. 3. INCORRECT: Resisting care could be related to the discomfort of frequent turning and cleaning of the skin breakdown, even though this activity is necessary. It is important for hospitalized clients to remain mobile if possible, and encouraged to participate in care. But this is not the greatest concern. 4. INCORRECT: There is no data on why the client was hospitalized; therefore, abdominal cramping may be an already existing symptom. This is not the most concerning problem currently.

What should the nurse monitor for when caring for a client receiving an IV of 1/2 Normal Saline at 100 mL/hr? 1. Hypertension 2. Fluid volume deficit 3. Hypernatremia 4. Pulmonary edema

2. Correct: 1/2 Normal Saline is a hypotonic solution. Monitor for cellular edema because the fluid is moving out to the cell which could lead to fluid volume deficit and decreased blood pressure. 1. Incorrect: Hypertension can occur with isotonic and hypertonic IV solutions. Hypotension can occur with hypotonic IV solutions such as 1/2 Normal Saline. 3. Incorrect: Hypernatremia can occur with isotonic and hypertonic sodium solutions. 4. Incorrect: This is a nursing alert for hypertonic IV solutions.

The nurse manager is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? 1. The client who requests that the rails be placed in the up position. 2. The client who is confused and wanders about the unit. 3. The client who is ambulatory and places the side rails up without staff assistance. 4. The client who asks the family to place all the rails up before leaving.

2. Correct: The intent of the side rails in the up position is to limit movement; therefore, they are considered a restraint. The nurse cannot restrain or limit a client's movement without a primary healthcare provider prescription. 1. Incorrect: The client may request that side rails be raised at any time. 3. Incorrect: The ambulatory client can put his/her own side rails up if that increases feelings of security. 4. Incorrect: The family may place the rails up at the request of the client. That action would not be considered a restraint.

The nurse is caring for a client with a fibula fracture. The primary healthcare provider makes rounds and writes prescriptions. What is the nurse's best action? MSO4 8 mg IM now Advance diet as tolerated Hgb and Hct in AM 1. Check the prescription prior to sending it to the pharmacy. 2. Clarify the prescription with the primary healthcare provider. 3. Notify the pharmacy that the prescription is needed immediately. 4. Gather the supplies needed for an injection.

2. Correct: The nurse should notify the primary healthcare provider because MSO4 is an unapproved abbreviation that presents safety concerns. MSO4 is the abbreviation for morphine sulfate. MgSO4​ ​is the abbreviation for magnesium sulfate. Notifying the primary healthcare provider to clarify the prescription will prevent a medication error. 1. Incorrect: The prescription should not be sent to the pharmacy until after it is clarified with the primary healthcare provider. The Institute for Safe Medication Practices and The Joint Commission recommend using the complete names for morphine and magnesium to eliminate confusion. 3. Incorrect: MSO4 is not an approved abbreviation. Before notifying the pharmacy, make sure you know what the prescription is for. The complete drug name should be written out. 4. Incorrect: You might be making a medication error if you assume you know what you are giving. Always seek clarification when in doubt.

A home health nurse is caring for a Mexican-American client who has been discharged from the hospital post-myocardial infarction. While the nurse is at the house, a curandero is also at the home at the request of family members. What is the best action of the nurse? 1. Leave, and return once the curandero has left. 2. Discuss the plan of care with the client, family, and curandero. 3. Ask the curandero to leave so that the client can be assessed. 4. Explain to the family that the curandero is not a reliable healthcare option.

2. Correct: This is the best course of action for the nurse. The health and healing of a client come from many components, including spirituality, religion, folk remedies, alternative therapies, and modern medicine. Unless something is harmful to the client, it is best to incorporate all components into the care of the person. 1. Incorrect: Leaving will not allow the nurse to discuss care of the client with all members of the healthcare team and family. This is a good time to learn about the curandero, health beliefs, etc. 3. Incorrect: The client and family have requested the curandero. Asking him to leave would be insulting. The nurse would not develop a good rapport with the client this way. 4. Incorrect: This does not take into account the client's beliefs in health, wellness, and illness. The nurse should work to incorporate folk medicine from the curandero as long as it will not harm the client.

Which client is legally able to sign a consent for surgery? Select all that apply 1. An 86 year old client who is disoriented. 2. A 62 year old client who speaks only Spanish. 3. A 41 year old client who just received midazolam. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. 5. A 44 year old with schizophrenia who is hallucinating.

2., & 4. Correct: The Spanish speaking client should have a trained medical interpreter, either in person,by telephone, or by video conference, but the client can still sign the consent. The 17 year old client is considered a minor, however, since the parents are not available, the emergency exception rule, known as "implied consent" would be followed. The primary healthcare provider must document the nature of the emergency, the reason why immediate treatment is required, and the attempts to obtain consent from the minors parents or legal guardian. 1. Incorrect: The 86 year old client who is disoriented is not considered capable of making an informed decision. 3. Incorrect: Midazolam is a benzodiazepine administered for preoperative sedation/amnesia. For a consent to be legally valid, the consent must be signed prior to being administered preoperative medication or other mind-altering medications. 5. Incorrect: This client with schizophrenia who is hallucinating does not have the ability at this time to understand explanations, understand risks and benefits, and communicate a decision based on that understanding.

The nurse should wear gloves when administering which medication? Select all that apply 1. Lorazepam 1mg orally. 2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 4. Metronidazole 500mg intravenous piggyback. 5. Humalog 8 units subcutaneously.

2., 3., & 5. Correct: You do not want to get nitroglycerin on your hands. The medication would be absorbed into your skin. When giving a medication intramuscularly or subcutaneously, there is a chance of being exposed to blood. Remember to wear gloves when there is a chance for you to encounter body fluids. 1. Incorrect: Gloves are not needed when administering oral medications unless contact with client's mucous membranes is anticipated or the medication is hazardous. 4. Incorrect: Gloves are not needed when preparing antibiotics such as ceftriaxone by IV piggyback.

A client reports difficulty sleeping since starting a new job. The nurse's assessment identifies that the client is also working after hours from home. Which teachings are appropriate to promote sleep in this client? Select all that apply 1. Vary bedtimes to determine time best to promote sleep. 2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.

2., 3., 4. & 5. Correct: The client should associate bed with sleep, not work. Eating late in the evening may interfere with sleep, especially if a heavy meal. Caffeine late in the evening may increase alertness and interfere with sleep. Many people respond positively to white noise. Music, on the other hand, may make it more difficult to sleep. 1. Incorrect: The same time for bed each day will establish a routine and make sleep easier. Varying sleep times will disturb the client's sleep cycle and circadian rhythm. This would not be helpful to facilitate sleep.

The nurse is making a home assessment for the purpose of preventing injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this assessment? Select all that apply 1. Episodes of mild anxiety 2. Rugs secured to the floor 3. Adequate lighting 4. Functional eye glasses 5. Client is wearing well-fitting closed toe shoes

2., 3., 4. & 5. Correct: Throw rugs may cause falls, as the client may trip. Diabetes may also impact sensation to know there is a rug in place. Adequate lighting is important so that the client does not bump into furniture or miss a step when navigating stairs. The visually impaired client needs functioning glasses to maximize sight and safety within the home. Diabetic clients do not need open toed shoes, as injury may occur to the foot and the client may not actually be aware of it. Also, wearing sandals is a risk to the person who is visually impaired and elderly, as the shoe may come off unexpectedly. 1. Incorrect. While depression is common and may result in self harm for elderly clients, anxiety is not likely to result in injury. Depression assessment should be performed on all elderly clients.

A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply 1. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 2. Use a new cotton ball for each cleansing wipe. 3. Instill artificial tears into the lower eye lids as prescribed. 4. Protect the eyes with a protective shield. 5. Monitor eyes for redness, and exudate.

2., 3., 4., & 5. Correct: All of these interventions are appropriate for eye care of the comatose client. These actions will prevent infection, keep eyes moist, and protect the eyes from injury. 1. Incorrect: Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct.

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? Select all that apply 1. When sitting, keep knees slightly lower than the hips. 2. Avoid movements that require spinal flexion with straight legs. 3. Squarely face the direction of anticipated movement. 4. Pivot to turn while holding an object. 5. Wear comfortable, low-heeled shoes.

2., 3., 4., & 5. Correct: Flexion the spine with the legs straight (toe-touches, sit-ups) will injure the back. Avoid twisting of the back by squarely facing the direction of movement. Move toward or away from your center of gravity. Pivoting is a technique in which the body is turned in a way that avoids twisting of the spine. Comfortable, low heeled shoes provide good foot support ad reduce the risk of slipping stumbling, or turning your ankle. 1. When sitting, keep knees slightly higher than the hips.

A client with a new colostomy is learning to perform a colostomy irrigation. The nurse knows the teaching was successful when the client makes what statement? 1. "My spouse can verbalize all the steps in order." 2. "I have attended all the sessions on ostomy care." 3. "I can do the irrigation if I refer to the instructions." 4. "I don't need to irrigate if the ostomy is making stool."

3. CORRECT: The true test of learning is for the client to be able to actually complete a self-care task independently. There is nothing wrong with the client referring to written instructions to complete the task. 1. INCORRECT: While it is beneficial for another family member to be familiar with the process of ostomy irrigation, having the spouse recite the steps does not ensure the client has learned successfully. 2. INCORRECT: Though the client has attended all the teaching sessions presented on performing self-ostomy care, that fact does not guarantee the client could actually successfully complete the task. 4. INCORRECT: A surgeon generally will order daily irrigation of a new ostomy to help establish a consistent bowel pattern. Only the surgeon can determine when the client may discontinue ostomy irrigation. This scenario is focused on teaching and learning. The true test of a client's successful learning is a return demonstration of that task by the client. In this situation, the task is to irrigate a new colostomy. A surgeon often orders irrigations to help establish a normal, daily bowel pattern with new ostomies. A client facing such issues can quickly become overwhelmed with all that is involved in caring for an ostomy, plus the need to irrigate. Recall when you were a new student on the clinical floor and were asked to complete a task. It was very scary and it was easy to forget a step when being watched. Well, clients are just the same. A client may nod in agreement to questions about completing the process, but hearing and doing are totally different! NCLEX® questions that seek to verify successful teaching include the client physically completing the action properly to prove that learning has actually occurred.

How closely monitored is access to a facility's health information system? 1. No monitoring; the system is password protected. 2. Monitored intermittently. 3. Monitored closely and constantly for inappropriate use. 4. Monitored daily and sporadically.

3. Correct: Access to a health care facility's computerized health information system is monitored closely and constantly. Records of each healthcare team member's time and date of access, as well as the information that was accessed, are kept by the information technology services department. Access can be suspended, restricted, or revoked for unauthorized or inappropriate use. 1. Incorrect: This is like doing nothing. Healthcare providers must be diligent about maintaining confidentiality, which includes the use of technology that contains confidential client information. 2. Incorrect: Intermittent monitoring is not adequate. Access should be monitored closely and constantly. A breach of confidentiality could occur if intermittent monitoring was done. 4. Incorrect: Access should be monitored closely and constantly. Sporadically and once daily is not adequate for protecting client confidentiality.

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.

After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do next? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. 3. Notify the coroner that the family is Jewish. 4. Call the rabbi of the family's synagogue to discuss the nature of the autopsy.

3. Correct: It is important to know about the Jewish culture to answer this question. Mutilation of the body is forbidden. Autopsy is allowed only when mandated by civil authorities, such as when murder is suspected. If an autopsy is performed, all body parts must be returned for burial. 1. Incorrect: Permission is not needed when foul play is suspected. The keyword is "unexpected". The law can require an autopsy be performed when death is the result of foul play, homicide, suicide or accidental causes such as motor vehicle crashes, falls, the ingestion of drugs or deaths within 24 hours of hospital admission. 2. Incorrect: The nurse has calmed the mother. The sedative is not needed and does not solve this problem. Remember to stay away from medications as long as possible. 4. Incorrect: A rabbi is usually requested at the time of death, but this will not solve the autopsy problem. The rabbi may pray in a minyan, a group of 10 adults over the age of 13.

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? pH - 7.5 PaO2 - 94% PaCO2 - 58 HCO3 - 35 1. Partially compensated metabolic acidosis 2. Partially compensated respiratory alkalosis 3. Partially compensated metabolic alkalosis 4. Partially compensated respiratory acidosis

3. Correct: Partially compensated metabolic alkalosis is indicated by these ABGs. The pH is 7.5 (normal 7.35-7.45) which is high, which means alkalosis. The PaCO2 is 58 (normal 35-45) which is high. Greater than 45 is acidosis from too much CO2. The HCO3 is 35 (normal 22-26) which is high. A high bicarb level equals alkalosis. The HCO3 matches the pH as both indicate alkalosis. The initial problem was a kidney problem or metabolic alkalosis. The lungs are trying to compensate by holding on to more acid. So the correct answer is Option 3: Partially compensated metabolic alkalosis. 1. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect. 2. Incorrect: The PaCO2 would be low rather than high if the problem was respiratory alkalosis. 4. Incorrect: A pH of greater than 7.45 indicates alkalosis rather than acidosis. So this option is incorrect.

A recently hired nurse is distressed that the facility's documentation system has been upgraded to a more challenging process, including the use of laptops in client rooms. The new nurse expresses concerns to the nurse manager, indicating an inability to learn the new process. What comment by the nurse manager is most appropriate? 1. "Of course you can do this, and I will help you! " 2. "Why does this new system upset you so much?" 3. "It is hard to deal with so many changes at once." 4. "This is so easy, even a child can learn how to do it."

3. Correct: This open-ended statement provides the opportunity for the nurse to express feelings not just about the new system, but also regarding any additional concerns. This option focuses on the new nurse's emotions rather the just the computer changes. 1. Incorrect: Although this response by the nurse manager may seem encouraging, particularly with the offer to help, it dismisses the new nurse's emotions. This is a closed-ended response that does not encourage the further expression of feelings. 2. Incorrect: Anytime a question demands an explanation, the situation is non-therapeutic. The nurse manager is making the assumption it is only the new system which is upsetting the nurse, and is focusing on the charting rather than the new nurse's feelings. 4. Incorrect: Although the nurse manager may have meant to be encouraging, this statement is rather demeaning. This does not create a positive learning environment and may discourage the new nurse even further.

A recently hired primary healthcare provider from India has started working at the local hospital. When receiving new phone prescriptions, the nurse is unable to understand the primary healthcare provider's thick accent. Which comment by the nurse is most likely to successfully resolve the issue? 1. "I'll have to get someone who can understand you." 2. "I can't understand you. You need to say it again." 3. "Can you please repeat that prescription again slowly? " 4. "I don't know what you are trying to say."

3.CORRECT: The issue involves difficulty understanding the verbal phone prescriptions rom the new primary healthcare provider. Any comment by the nurse must be both professionally worded and culturally sensitive. In this statement, the nurse is asking for the orders to be repeated and indicating the need to speak slowly. This does not place blame on the healthcare provider but does suggest a process to resolve the situation in a professional manner. 1. INCORRECT: This response is not the best. It may imply cultural insensitivity and that the inability to communicate is solely the fault of the primary healthcare provider. 2. INCORRECT: This may be a truthful statement, but it is not professionally stated. This phrasing by the nurse suggests that the problem is the fault of the primary healthcare provider. Additionally, the manner in which the nurse asks the prescription to be repeated sounds abrupt and demanding. 4. INCORRECT: There is no attempt by the nurse to resolve the situation with any suggestions, which is both culturally insensitive and unprofessional. A tone of frustration would not help the nurse to clarify the prescription.

A 20 year old client has been admitted to the hospital with a diagnosis of preeclampsia. The charge nurse has only semiprivate rooms available. What roommate would be most appropriate for this client who is being admitted? 1. An adolescent primigravida with many visitors. 2. A 25 year old post induction for fetal demise. 3. A 35 year old awaiting discharge after a total abdominal hysterectomy (TAH). 4. A 30 year old post dilation and curettage (D&C) who enjoys knitting.

4. CORRECT: A client with preeclampsia will be experiencing stress and elevated blood pressure. There is a risk of seizures, and therefore a calm, relaxed environment would provide the most therapeutic setting for the client. The 30 year old client is ideal because knitting is a quiet activity. Additionally, a D&C is a relatively uncomplicated procedure and this client will most likely soon be discharged, leaving the preeclampsia client alone in that room. A client with preeclampsia has an extremely elevated blood pressure, usually ankle edema and proteinuria. The greatest concern is that the client will begin to seize, which decreases the perfusion to the placenta and fetus. While the client will be given appropriate medications to decrease the chance of seizures, another important aspect of care is to provide a calm, relaxed environment for this client. 1. INCORRECT: Although the client is close in age to the adolescent, the teenaged primigravida has many young visitors which would create noise or confusion in the environment. Since this client is suffering from preeclampsia, a quiet environment is necessary to prevent other complications such as seizures. This adolescent would not be the best roommate. 2. INCORRECT: The client is admitted with a diagnosis of preeclampsia, which means elevated blood pressure, edema and the possibility of seizures. A quiet calm environment would be crucial for this client. The 25 year old client is close in age; however, that client has experienced a fetal demise and delivery of that fetus. There will most likely be grieving, multiple family members, and tension in that environment which would not be helpful to the client with preeclampsia. 3. INCORRECT: Though there is a large age difference, that issue does not impact whether this client would be an appropriate roommate. A client with preeclampsia needs a restful, calm environment to prevent further complications. Depending on the reason for the total abdominal hysterectomy (TAH), this client may require special teaching, referrals for further care and treatment, or emotional support for an unexpected diagnosis. The charge nurse knows this may be too hectic of an environment for the client with preeclampsia.

The nurse has a prescription to calculate a client's body mass index (BMI). The client weighs 150 kgs and is 1.8 m tall. Determine the BMI to the whole number.

BMI = weight in kilograms / height in meters squared First we multiply the client's height by itself: 1.8 x 1.8 = 3.24 ² Next we divide the client's weight by the height in meters ²: 150 / 3.24 = 46.3 The client's BMI is 46.3 or 46

A nurse auscultates the bowel sounds of a client suspected of having a bowel obstruction in the transverse colon. What sounds would the nurse expect to hear in the abdominal quadrants? Select all that apply 1. Absent RLQ 2. Increased RLQ 3. Decreased RLQ 4. Increased LLQ 5. Decreased LLQ

2. & 5. Correct: Peristalsis should increase in the ascending colon (RLQ) in an attempt to clear the blockage resulting in hyperactive bowel sounds. There will be little or no peristalsis distal to the obstruction (LLQ) resulting in decreased or absent bowel sounds. 1. Incorrect: Bowel sounds should be present proximal to the blockage (RLQ). 3. Incorrect: Peristalsis will increase proximal (RLQ) to the obstruction. 4. Incorrect: Peristalsis will be decreased or absent distal to the obstruction (LLQ).

A client with a supra-pubic catheter is admitted for surgery and requires a catheter change before that procedure. The nurse is aware the most important action prior to changing this catheter is what? 1. Check size of existing catheter and balloon. 2. Ask client when the catheter was last changed. 3. Clamp and empty the present catheter bag. 4. Gather clean gloves and basin of hot soapy water.

1. CORRECT. It is important to maintain the same catheter size as the one currently in use since the surgical opening does not increase in size like a urethral opening. If the balloon is too small, urine can leak through the opening. If the balloon is too big, urine will not drain properly, leaving residual and the potential for infection. 2. INCORRECT. Though obtaining information directly from the client is often a good choice, the individual may not be able to recall a precise date or time. When a catheter change is scheduled at specific time intervals, the nurse needs to verify the correct time line. Generally, the primary healthcare provider can provide a current order to facilitate the changing of the catheter. 3. INCORRECT. Although the nurse may empty a catheter bag, if the client uses one, there is no need to clamp a suprapubic catheter. The standard procedure for replacing a suprapubic catheter does not include clamping since the catheter does not require long tubing like a regular catheter. Also, urine bags are generally emptied at scheduled times each shift. 4. INCORRECT. Replacing a suprapubic catheter requires the use of sterile gloves both while cleaning and inserting the new catheter. Also, care of the insertion site is completed with sterile normal saline before and after the reinsertion. A suprapubic catheter is a urinary catheter that is not inserted through the urethra; rather, it is surgically inserted into the bladder through an opening created a couple inches below the navel, just above the pubic bone. There are many reasons why this urinary diversion may be created. The client who needs a catheter due to either retention or incontinence, but wishes to remain sexually active, would find this approach more appropriate. The client may suffer from pelvic organ prolapse, serious spinal injuries, BPH, trauma or even multiple sclerosis. The urethra may have been damaged, or the client is paraplegic. Whatever reason a suprapubic catheter is chosen, many clients find it easier to perform self-catheter care. There are fewer infections with this type of catheter and no genital damage as occurs with long-term urethral catheters. While there are some potential complications such as bladder spasms or drainage around the insertion site, many clients feel the abdominal approach is more comfortable. The procedure for changing this catheter is like that of a urethral catheter. The first catheter is placed by the surgeon while creating the abdominal opening; then, subsequent catheter changes can be completed by the nurse. Depending on prescriptions from the primary healthcare provider or surgeon, a suprapubic catheter can be changed anywhere between 4 and 12 weeks. There is also the possibility that a "valve" could be attached, allowing the client to empty the bladder through this catheter without utilizing a bag. Self-care is slightly different for clients with this catheter. Drinking large amounts of water is important, as it is with all catheter clients; however, the client cannot take a bath and, when showering, must cover the insertion site to prevent contamination. The client is instructed to 'rotate" or turn the catheter gently in a circular motion daily to prevent adherence to the bladder wall. Increased fiber is important to prevent constipation and cleaning the insertion site twice daily is needed to prevent infection. While it is possible to secure the catheter, most clients find securing catheter with a special abdominal attachment is more comfortable than securing to the thigh.

The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health. 2., 3., & 4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies.

What is the best method for the nurse to verify correct nasogastric (NG) tube placement after insertion? 1. X-ray of the upper GI 2. Gastric aspiration and pH testing 3. Auscultation of air instilled into the stomach 4. Visualization of the tube markings

1. Correct: The gold standard for nasogastric feeding tube placement is radiographic confirmation with X-ray. This is the most reliable method! 2. Incorrect: Both respiratory and gastrointestinal aspirates may be similar in color and may be misinterpreted. 3. Incorrect: This method cannot differentiate tube placement in the stomach or lung. The practitioner may still hear a rush of air. 4. Incorrect: Visualization of tube markings does not provide a reliable verification that the tube is in the stomach. This has never been a reliable way of verifying placement.

The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Request the surgeon visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the surgeon explained those options yesterday.

1. Correct: The surgeon is responsible for informing the client about the surgical procedure, the options available,and the benefits and risks of each treatment modality. So, if the client has concerns the surgeon should be told and requested to see the client again prior to surgery. Surgery should be delayed until the client is sure of decision. 2. Incorrect: The consent form signature is important; however, the client has the right to have questions answered and to change his mind. 3. Incorrect: The client should not be encouraged to have the surgery if he still has questions about other options. The consent must be informed, so the client must have all questions answered. The surgery can be delayed until the client's concerns are addressed. 4. Incorrect: The surgeon may have explained the options, however; it is obvious that the client did not understand the options. The client's concerns must be addressed prior to surgery.

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. 1) Advance NG tube upward and backward. 2) Rotate catheter and pass the tube into nasopharynx. 3) Secure NG tube. 4) Have client swallow ice as NG tube advances into stomach. 5) Insert NG tube into unobstructed naris. 6) Measure distal NG tube from nose tip to earlobe to xiphoid process. 7) Lubricate 2-3 inches (5.08-7.62 cm) of distal NG tube. 8) Elevate head of bed to Fowler's position.

First, raise the client's head of bed to fowler's position Second, measure the distal NG tube from the nose tip to the earlobe to the xiphoid process. Third, lubricate 2-3 inches (5.08-7.62 cm) of the distal NG tube. Fourth, insert the NG tube into unobstructed naris. Fifth, advance NG tube upward and backward. Sixth, rotate catheter and advance into nasopharynx. Seventh, have client swallow ice to pass the NG tube into the stomach. Eighth, secure the NG tube. The tube is then advanced past the nasopharynx. The client is then asked to take sips to help with tube advancement into the stomach. Finally, the tube is taped once placement is assured. The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question.

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take first? Select all that apply 1. Consult with the primary healthcare provider. 2. Assess the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

Pain assessment is considered the fifth vital sign. And remember that pain is what the client says it is. Nurses should not be judgmental and stereotype clients based on the nurse's own beliefs. The nurse coming on duty must carefully assess the client independently and without bias. 2. & 5. Correct: The nurse should carefully assess the client. The nurse must serve as an advocate for the client. A pain scale is used to determine level of pain. 1. Incorrect: The nurse must assess the client before consulting with the primary healthcare provider about the medication. 3. Incorrect: This action assumes that the client does not have pain, which does not take into consideration what is wrong with the client. 4. Incorrect: This action assumes that the client is a "drug seeker". The nurse must carefully assess the client.

The home health nurse is caring for a client who is identified as high risk for falls. What evaluation would indicate a therapeutic response to home fall prevention education? Select all that apply 1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime. 3. Only uses assistive devices when leaving home. 4. Goes barefoot while in the home. 5. Uses throw rugs in walking areas to prevent slipping.

1. & 2. Correct: Placing a grab bar in a slippery tub can assist the client in getting into and out of the tub. Turning on night lights at night ensures that the client can navigate safely, thus reducing the risk of falls. 3. Incorrect: If the adult has an assistive device, it should be used inside and outside the home. The client should be encouraged to use assistive devices, such as canes or walkers, at all times. 4. Incorrect: The client should always wear properly fitting shoes that have nonskid protection. The client increases their risk for injury when properly fitting shoes are not worn. 5. Incorrect: Throw rugs actually may increase the risk of tripping.

The nursing supervisor is preparing a staff development program concerning the legal parameters of torts. Which example would the supervisor include as an intentional tort? Select all that apply 1. Administering a 0900 medication at 1030. 2. Administering a medication to an incorrect client. 3. Performing an invasive procedure without an informed consent. 4. Telling a client that their medication will be withheld if client does not behave. 5. Raising the side rails without a prescription when a client is at risk to fall.

3., & 4. Correct: An intentional tort occurs when a person intends to perform an action that causes harm to another. Performing an invasive procedure without consent is considered battery because the client has not given consent for the procedure. Threatening to withhold a medication is intentionally threatening to harm the client by not administering the medication. 1. Incorrect: This is an unintentional tort. The nurse did not intend to administer the medication 90 minutes after the ordered time. 2. Incorrect: The nurse unintentionally jeopardized the safety of the client. This is an unintentional tort. 5. Incorrect: This intervention by the nurse is appropriate. In an emergency the side rails maybe raised when the safety of the client is at risk.

A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."

4. CORRECT: Compression stockings are used to prevent the formation of blood clots, reduce the diameter of distended veins and decrease stasis. Usually these stockings are ordered to be applied upon rising in the morning and removed at night, depending on the disease process. The client's comment suggests the difficulty of putting the hose on may lead to not wearing the stockings consistently. 1. INCORRECT: This statement by the client indicates a positive attitude about the need to lose weight and the intention of following the prescribed diet. Obesity is one of several main factors that can lead to the development of DVTs. 2. INCORRECT: Prolonged sitting, or even lying down, can increase the incidence of blood clots or DVTs. If the client does a lot of sitting during the day, it is advisable to walk around every few hours to reduce stasis. The client is acknowledging the need to increase mobility regularly, which is an indication of compliance. 3. INCORRECT: Placing pressure directly on vessels by crossing the legs compresses both veins and arteries, thus increasing the potential for blood clots or dislodging an unknown clot. The client has acknowledged the need to keep legs uncrossed and the benefit of having family provide reminders.

The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is important to preserve client's self-esteem as the task is completed? 1. Closes the door for privacy. 2. Introduces self and explains the procedure. 3. Bathes the client without the help of others. 4. Covers the client with a bath blanket.

4. Correct: The client does not have to be exposed during the bed change and should be covered with a bath blanket as the top sheet is removed. A bath blanket covers the client as once section at a time of the body is exposed and bathed. This allows for the most privacy and protects self-esteem. 1. Incorrect: Closing the door is very important but the client's privacy should be maintained at all times even from the nurse administering the bath. A bath blanket promotes privacy and protects the self-esteem. 2. Incorrect: Introducing yourself to the client and explain procedures shows respect. These two actions do not provide for privacy and preserve the self-esteem of the client. 3. Incorrect: If help is needed during an occupied bed bath to protect the client and provide for safety, help should be obtained. The nurse should use measures to protect privacy and preserve the client's self-esteem.