HESI Prep: Fundamentals - Fundamental Skills

The nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." Which does this nurse's comment reflect? 1. Demonstration of a personal bias 2. Problem-solving based on assessment 3. Determination of client acuity to set priorities 4. Consideration of the complexity of client care

1. Demonstration of a personal bias When nurses make judgmental remarks and client needs are not placed first, the standards of care are violated and quality of care is compromised. Assessments would be objective, not subjective and biased. There is no information about the client's acuity to come to this conclusion regarding priorities. The statement does not reflect information about complexity of care.

Which goals of care are associated with the family health system model? 1. Improving family health or well-being 2. Preparing for family transitions later in life 3. Providing assistance in family management off illness conditions 4. Promoting positive family behaviors to achieve essential tasks 5. Achieving health outcomes related to the family's areas of concern

1. Improving family health or well-being 3. Providing assistance in family management off illness conditions 5. Achieving health outcomes related to the family's areas of concern When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse would help the family prepare for later transitions and promote positive family behavior to achieve essential tasks.

Which factor(s) increase(s) the risk of nurses making medication errors in the health care setting? Select all that apply. One, some, or all responses may be correct. 1. Stress 2. Fatigue 3. Overwork 4. Equipment malfunction 5. Increased documentation

1. Stress 2. Fatigue 3. Overwork Factors that can lead to nurses making medication errors include stress, overwork, and fatigue. Equipment malfunction can lead to injury. Increased documentation can lead to decreased time for the nurse to spend with the client, but this does not cause medication errors.

A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container? 1. The local hazardous waste collection site 2. The regular household trash 3. The local health department for disposal 4. The Environmental Protection Agency (EPA) through the mail

1. The local hazardous waste collection site Each state (province) has its own waste management guidelines for proper disposal of sharps containers, as well as hazardous waste collection sites. Clients cannot place needles in the regular household trash because sharps are considered medical waste. The local health department does not collect sharps containers. Sharps containers are not mailed directly to the EPA.

Which fine motor skills may be observed in an 8- to 10-month-old infant? Select all that apply. One, some, or all responses may be correct. 1. Using pincer grasp well 2. Picking up small objects 3. Showing hand preference 4. Crawling on the hands and knees 5. Pulling oneself to standing or sitting

1. Using pincer grasp well 2. Picking up small objects 3. Showing hand preference The fine motor skills evident in 8- to 10-month-old infants include the accurate use of the pincer grasp and picking up small objects. At this stage, infants may also demonstrate a hand preference. Crawling on the hands and knees and pulling oneself to a standing or sitting position are considered gross motor skills.

Arrange the order of critical thinking for an existing problem. Analyzing information about the issue Making a conclusion Evaluating the information Recognizing the existing issue

1.Recognizing the existing issue 2.Analyzing information about the issue 3.Evaluating the information 4.Making a conclusion When a problem exists, the nurse first recognizes the existing issue, then analyzes information about the issue and evaluates the collected information about the issue. After evaluating, the nurse would make a conclusion.

The nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital problems. Which statement by the UAP would the nurse recognize as providing false reassurance? 1. "I agree; I think you should get a divorce." 2. "Everything will be fine; just wait and see." 3. "You should be glad that you have such a loving family." 4. "In the scheme of things, you do not have a major problem."

2. "Everything will be fine; just wait and see." Saying that everything will be fine provides false hope. Agreeing with the client is an example of offering approval. Commenting on how a client should feel is an example of being judgmental. Implying that the problem is minor is an example of minimizing.

The nurse teaches a client about wearing thigh-high antiembolism elastic stockings. Which instruction would be correct to include? 1 "You do not need to wear them while you are awake, but it is important to wear them at night." 2. "You will need to apply them in the morning before you lower your legs from the bed to the floor." 3. "If they bother you, you can roll them down to your knees while you are resting or sitting down." 4. "You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor."

2. "You will need to apply them in the morning before you lower your legs from the bed to the floor." Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

A client has seeds containing radium implanted in the pharyngeal area. Which would the nurse include in the client's plan of care? 1. Have the client void every 2 hours. 2. Maintain the client in an isolation room. 3. Spend time with the client to allow verbalization of feelings. 4. Wear two pairs of gloves when touching the client during care.

2. Maintain the client in an isolation room. During radiation therapy with radium implants, the client is placed in isolation so that exposure to radiation by family and staff is decreased. Voiding every 2 hours is unnecessary; a full bladder will not disrupt the seeds. Excess exposure to radiation is hazardous to personnel. Gloves will not protect the nurse from radiation.

Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress? 1. Sharing hope 2. Sharing humor 3. Sharing empathy 4. Sharing observations

2. Sharing humor Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses would recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client communicate without the need for extensive questioning, focusing, or clarification.

Which action would the nurse take when observing that a postsurgical client has a urine output of 800 mL total in the first 24 hours after surgery? 1. Notify the provider. 2. Increase oral fluid intake. 3. Document the normal finding. 4. Begin an intravenous infusion of normal saline.

3. Document the normal finding. A low urine output of 800 to 1500 mL is normal in the first 24 hours after surgery. The nurse would document the normal finding and continue to monitor urine output in the postoperative period. It is not necessary to increase oral or intravenous fluid intake or notify the provider unless urine output does not increase.

Which intrinsic factor is associated with the fall of an older adult? 1. Wet floors 2. Poor lighting 3. Lack of exercise 4. Inappropriate footwear

3. Lack of exercise. Intrinsic risk factors associated with the fall of an older adult may include a lack of exercise or deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

Which nursing interventions indicate client care that supports physical functioning? Select all that apply. One, some, or all responses may be correct. 1. Facilitate client's learning. 2. Alter client's undesirable behavior. 3. Maintain client's nutritional status. 4. Maintain client's regular bowel patterns. 5. Prevent complications in the client related to electrolyte imbalance.

3. Maintain client's nutritional status. 4. Maintain client's regular bowel patterns. Providing interventions to maintain the client's nutritional status and providing interventions to maintain the client's regular bowel patterns are interventions that support physical functioning. Providing interventions to facilitate a client's learning and providing interventions to alter the client's undesirable behavior are interventions to support psychosocial functioning and facilitate lifestyle changes, respectively. Providing interventions to prevent complications related to electrolyte imbalance indicates the nursing care that supports homeostatic regulation.

An older adult is experiencing emotional stress after a recent surgery. Which intervention would be most appropriate for the client? 1. Touch 2. Reminiscence 3. Reality orientation 4. Validation therapy

3. Reality orientation A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation. Touch is a therapeutic tool that helps induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help the client in a confused state.

Which is the most important nursing intervention when working with an older adult client? 1. Encouraging frequent naps 2. Strengthening the concept of ageism 3. Reinforcing the client's strengths and promoting reminiscing 4. Teaching the client to increase calories and focusing on a high-carbohydrate diet

3. Reinforcing the client's strengths and promoting reminiscing Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

Which principal components are associated with the nurse's time management skills? Select all that apply. One, some, or all responses may be correct. 1. Autonomy 2. Goal setting 3. Priority setting 4. Interruption control 5. Right communication

2. Goal setting 3. Priority setting 4. Interruption control Goal setting, priority setting, and interruption control are the principal components of time management. Autonomy is an important component of the decision-making process. Right communication is considered one of the rights of delegation.

Which therapeutic communication technique is used when the nurse and a client have a conversation and the client begins to repeat the conversation to her- or himself? 1. Focusing 2. Clarifying 3. Paraphrasing 4. Summarizing

1. Focusing Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.

Which activity can be performed by infants aged 6 to 8 months? 1. Holding a pencil 2. Showing hand preference 3. Placing objects into containers 4. Transferring objects from hand to hand

4. Transferring objects from hand to hand Infants aged 6 to 8 months may be able to transfer objects from hand to hand. Infants aged 10 to 12 months may be able to hold a pencil. Infants aged 8 to 10 months may show a hand preference. Infants aged 10 to 12 months may be able to place objects into a container.

Arrange these fine motor skills in ascending order as the infant develops them. Uses pincer grasp Places objects into containers Displays reflexive grasp Pulls feet to the mouth Looks at and plays with fingers Bangs objects together

Displays reflexive grasp Looks at and plays with fingers Pulls feet to the mouth Bangs objects together Uses pincer grasp Places objects into containers The infant begins to develop fine motor skills within the first month of birth. The reflexive grasp is seen in the first month. By the age of 2 to 4 months, the infant begins to look at his or her fingers and play with them. The infant is able to bring objects from the hand to the mouth. At 4 to 6 months, the infant begins to pull his or her feet to his or her mouth to explore. By the age of 6 to 8 months, the infant is able to hold objects and bang them together. The infant begins to crawl by the age of 8 to 10 months and uses a pincer grasp to pick up small objects. At this age, the infant also shows a hand preference. The infant is able to pick up objects and place them in containers by the age of 10 to 12 months.

Which skill in critical thinking requires the nurse to be orderly in data collection? 1. Analysis 2. Inference 3. Evaluation 4. Interpretation

Interpretation Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used. When the data collected about the client helps in solving an existing problem, then the skill called inference is being used. Evaluation is used when the results of nursing actions are determined.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? 1. Their gag reflex has returned. 2. They are confused due to anesthesia. 3. They are nauseated and want to vomit. 4. Their airway is becoming obstructed.

1. Their gag reflex has returned. The ability to spit out the oral airway indicates that the normal gag reflex has returned and the client can protect her or his airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit out the airway does not mean that the client is nauseated. An oral airway is meant to keep the airway patent; it may not obstruct the airway.

Which component of ethical decision-making refers to the duties and activities the nurse is employed to perform? 1. Authority 2. Autonomy 3. Responsibility 4. Accountability

3. Responsibility Responsibility refers to all duties and activities the nurse is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy refers to the freedom of making choices and the responsibility for making those choices. Accountability refers to individuals being answerable for their actions.

The nurse assesses an older adult client with cognitive impairment. Which statement(s) made by the client confirm the nurse's conclusion? Select all that apply. One, some, or all responses may be correct. 1. "I have difficulty judging things." 2. "I forget to take medicines." 3. "I am unable to do financial calculations." 4. "I get confused about the proper date and time." 5. "I am unable to recall words during conversations with my family."

1. "I have difficulty judging things." 3. "I am unable to do financial calculations." 5. "I am unable to recall words during conversations with my family." Poor judgment, loss of the ability to calculate, and loss of language skills are related to cognitive impairment. These changes may develop due to an imbalance of neurotransmitters in the brain. Forgetfulness and getting confused are symptoms that may be associated with normal aging changes.

The nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." Which response by the nurse is correct? 1. "Your wish will be respected." 2. "Why do you want to be called Doctor?" 3. "Residents here call one another by their first names." 4. "Wouldn't it be better if the others do not know you are a doctor?"

1. "Your wish will be respected." The client has the right to make this decision, and the staff should accept the client's wishes. The client has a PhD, and the nurse's statement "Why do you want to be called Doctor?" attacks the client's self-concept. The informality of using first names is not encouraged unless it is the client's choice. The nurse can and should honor the client's request.

Which is the most important nursing action involved in caring for a client receiving medications? 1. Administering the medications 2. Teaching about the medications 3. Ensuring adherence to the medication regimen 4. Evaluating the client's ability to self-administer medications

1. Administering the medications The most important part of the nursing practice regarding medication is administering the medications. Administering medications safely requires an understanding of the legal aspects of health care, pharmacology, pathophysiology, human anatomy, and mathematics. Teaching about the medications, ensuring adherence to the medications, and evaluating the client's ability to self-administer medications are responsibilities of the nurse performed before or after the administration of medicines.

Arrange the steps involved in the evidence-based practice process in the correct order. Ask a clinical question. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. Collect the most relevant and best evidence. Share the outcomes of evidence-based practice. Critically appraise the evidence you gather. Evaluate the practice decision or change.

1. Ask a clinical question. 2. Collect the most relevant and best evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change. 6. Share the Outcomes of evidence-based practice. Evidence-based practice is a problem-solving approach that integrates the conscientious use of best evidence in combination with a clinician's expertise, client preferences, and client values to make decisions about client care. First, the nurse would ask a clinical question and collect the most relevant and best evidence. Then, the nurse critically appraises the gathered evidence and integrates the evidence with his or her clinical expertise and the client's preferences and values to make a decision or change. Then the nurse evaluates the practice decision or change and shares the outcomes of the evidence-based practice changes with his or her team.

Which intervention would the nurse expect to implement to alleviate anxiety for a preoperative client? 1. Attempt to identify the client's concerns. 2. Reassure the client that the surgery is routine. 3. Report the client's anxiety to the health care provider. 4. Provide privacy by pulling the curtain around the client.

1. Attempt to identify the client's concerns. The nurse would assess the situation before planning an intervention. Reassuring the client that the surgery is routine minimizes concerns and cuts off communication. Reporting the client's anxiety to the health care provider is premature; more information is needed. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.

Which behavior by the client exhibits denial after a recent diagnosis? 1. Attempts to minimize the illness 2. Lacks an emotional response to the illness 3. Refuses to discuss the condition with the client's spouse 4. Expresses displeasure with the prescribed activity program

1. Attempts to minimize the illness Attempts to minimize the illness is a classic sign of denial; by reducing the importance or extent of the problem, the individual is able to cope. Not acknowledging that it is really a problem is a form of denial. Lacking an emotional response to the illness indicates repression of affect rather than denial. Failure to communicate is insufficient evidence to diagnose denial; the marital relationship may be strained, or the client may be worried about upsetting the spouse. Expressing displeasure with the activity program usually indicates displacement of anger, not denial.

The nurse is assessing a child who is accompanied by a parent and a stepbrother. Which kind of a family does this child belong to? 1. Blended family 2. Extended family 3. Alternative family 4. Single-parent family

1. Blended family The child belongs to a blended family. Such a family is formed when parents bring unrelated children from prior relationships into a new, joint living situation. Extended family comprises the husband, wife, children, uncles, aunts, cousins, and grandparents. An alternative family may have grandparents caring for grandchildren. It may also be a multi-adult household with cohabiting partners or homosexual couples. A single-parent family is formed when one parent cares for the children after the death, divorce, or desertion of the other parent. A single person may also decide to have or adopt a child.

A Spanish-speaking client is being cared for by English-speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client? 1. Contact an interpreter provided by the hospital. 2. Contact the client's family member to translate for the client. 3. Communicate with the client using Spanish phrases the nurse learned in a college course. 4. Communicate with the client with the use of a hospital-approved Spanish dictionary.

1. Contact an interpreter provided by the hospital. Interpreters provided by the health care organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate health care information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

Which is the correct nursing intervention when assessing a client with anxiety? 1. Divide the assessment and do it over shorter amounts of time. 2. Complete the client assessment in a shorter amount of time. 3. Postpone the client assessment until a more beneficial time. 4. Do the assessment in a soft-spoken voice for a longer duration.

1. Divide the assessment and do it over shorter amounts of time. The client with anxiety easily gets irritated, even over small issues. To reduce any aggressive behavior, the nurse does the assessment in multiple smaller appointments. The nurse may not gather adequate information if she or he completes the assessment in a shorter amount of time. Postponing the assessment may increase the risk for the client. Doing the assessment for a longer duration in a soft-spoken voice may cause irritation in the client.

The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? 1. Don an N95 respirator mask before entering the room. 2. Put on a permeable gown each time before entering the room. 3. Implement contact precautions and post appropriate signage. 4. After finishing with client care, remove the gown first and then remove the gloves.

1. Don an N95 mask before entering the room. An N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions, not contact precautions, are required. When finished with care, gloves would be removed first because they are the most contaminated.

A group of registered nurses (RNs) is involved in a campaign that promotes children's vaccinations. After the campaign's completion, the group prepares a report that counts the number of immunizations and compares it with last year's report. Which type of research is the group performing? 1. Evaluation research 2. Descriptive research 3. Experimental research 4. Correlational research

1. Evaluation research Evaluation research tests the effectiveness of a program, practice, or policy. It measures the outcomes of a campaign. Descriptive research measures the characteristics of persons, situations, or groups. For example, this study would measure the frequency of an occurrence of an event. In experimental research, the investigator controls the study variable and randomly assigns the subjects to different conditions for the variable test. Correlational research explores the interrelationships among variables of interest; this study does not include any active intervention by the researcher.

Which physiological changes are expected during the first trimester of pregnancy? Select all that apply. One, some, or all responses may be correct. 1. Fatigue 2. Increased libido 3. Morning sickness 4. Breast enlargement 5. Braxton Hicks contractions Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester of pregnancy. Braxton Hicks contractions are observed during the third trimester of pregnancy.

1. Fatigue 3. Morning sickness 4. Breast enlargement Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester of pregnancy. Braxton Hicks contractions are observed during the third trimester of pregnancy.

The nurse provides care for a Chinese client who is experiencing leg pain. The client states, "I don't want to take any medication that I may get addicted to." Which is the correct nursing intervention in this situation? 1. Give ibuprofen to the client with hot tea. 2. Give morphine to the client with hot tea. 3. Give ibuprofen to the client with cold water. 4 .Postpone medication administration to the client.

1. Give ibuprofen to the client with hot tea. People of Chinese descent may prefer to take medication with hot tea because of cultural beliefs that hot (or yang) foods have healing properties. Ibuprofen does not pose an addiction risk, so the client may feel more comfortable taking it rather than morphine. Together hot tea and ibuprofen may be the best way to treat this client. The nurse does not give morphine to the client, even with hot tea, because the client has already stated a desire to avoid addictive medications and the nurse does not want to force the client. The nurse does not offer cold water with the ibuprofen because a person from the Chinese culture may avoid drinking cold water and other cold liquids during an illness. Postponing the medication administration may increase the severity of the pain in the client, so this is not an appropriate intervention.

Which nursing intervention is classified under complex physiological domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. One, some, or all responses may be correct. 1. Interventions to restore tissue integrity. 2. Interventions to optimize neurological functions. 3. Interventions to manage restricted body movements. 4. Interventions to promote comfort using psychosocial techniques. 5. Interventions to provide care before, during, and immediately after surgery.

1. Interventions to restore tissue integrity. 2. Interventions to optimize neurological functions. 5. Interventions to provide care before, during, and immediately after surgery. Interventions such as restoring tissue integrity; optimizing neurological functions; and providing care before, during, and immediately after surgery are classified under the physiological domain according to the NIC taxonomy. Interventions to manage restricted body movements are classified under the simple physiological domain. Interventions to promote comfort using psychosocial techniques are classified under the behavioral domain.

Which nurse collaborates with the client to establish and implement a basic plan of care on admission? 1. Primary nurse 2. Nurse clinician 3. Nurse coordinator 4. Clinical nurse specialist

1. Primary nurse The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or health care provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. Clinical nurse specialist is a title given to the nurse specially prepared for one very specific clinical role. It requires a master's degree level of education.

The nurse is caring for a client who had a hip replacement 2 days prior. Which nursing intervention would the nurse perform next? 1. Provide perineal care. 2. Turn and position the client. 3. Give a complete bed bath. 4. Document the bowel movement.

1. Provide perineal care. Providing perineal care helps preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

An older adult in acute care has a risk of skin breakdown. Which intervention(s) is/are beneficial to the client? Select all that apply. One, some, or all responses may be correct. 1. Providing thorough skin care 2. Reducing shear forces and friction 3. Providing beverages and snacks frequently 4. Using a support surface base all the time 5. Avoiding pressure with proper positioning

1. Providing thorough skin care 2. Reducing shear forces and friction 5. Avoiding pressure with proper positioning Providing an older adult with meticulous skin care may reduce the risk of skin breakdown. Reducing shear forces and friction prevents the development of pressure injuries. Pressure can be avoided with proper positioning. Beverages and snacks are frequently provided to clients who are hospitalized due to dehydration. A supportive surface base is used based on risk factors.

Which would the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply. One, some, or all responses may be correct. 1. Refrain from smoking around the infant. 2. Refrain from co-sleeping or bed-sharing. 3. Position the infant on the side while sleeping. 4. Use soft pillows to support the infant while sleeping. 5. Refrain from placing stuffed toys on the infant's bed.

1. Refrain from smoking around the infant. 2. Refrain from co-sleeping or bed-sharing. 5. Refrain from placing stuffed toys on the infant's bed. The nurse would instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for SIDS. Co-sleeping or bed-sharing is also associated with SIDS. The nurse would ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk of SIDS.

Which action made by the client indicates that she or he is in the precontemplation stage of the transtheoretical model of change? 1. Refuses to think about changing 2. Intends to change in the next 60 days 3. Sustains the changed action for 6 months 4. Recognizes the advantages of the change

1. Refuses to think about changing The transtheoretical model of change model defines changing patterns in an individual in five stages based on beliefs of readiness to change. The phases are precontemplation, contemplation, preparation, action, and maintenance. The client refuses and does not think about the change in the precontemplation stage. The client intends to change in next 60 days in the preparation stage. The client recognizes the beneficial effects of the change and thinks about the change within 6 months in the contemplation stage. In the maintenance stage, the client sustains the changed action for 6 months and follows preventive measures to prevent relapse.

Which instructions to minimize the risk of falls in the home would the nurse provide the caregiver of an older client who requires the use of a walker with wheels? Select all that apply. One, some, or all responses may be correct. 1. Remove cords. 2. Apply bed alarms. 3. Use bright lighting. 4. Get rid of throw rugs. 5. Keep phone close by.

1. Remove cords. 3. Use bright lighting. 4. Get rid of throw rugs The nurse would instruct the caregiver to remove cords, use bright lighting, and eliminate throw rugs to prevent falls. Bed alarms are used in health care facilities. Keeping the phone close by will allow the older adult to obtain help, but this action does not prevent falls.

Which risk of adolescent pregnancy would the community nurse teach? 1. Risk for premature birth 2. Risk for having a large baby 3. Risk for chromosomal defects 4. Risk for increased weight gain

1. Risk for premature birth The nurse would teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected by lack of nutrition and exposure to alcohol, drugs, and tobacco.

A client has terminal cancer after 7 years of chemotherapy and surgeries. The nurse enters the client's room and finds the client crying. Which is the correct intervention by the nurse? 1. Sit down quietly next to the bed and allow her or him to cry. 2. Pull the curtain and leave the room to provide privacy for the client. 3. Explain to the client that her or his feelings are expected and they will pass with time. 4. Observe the length of time the client cries and document her or his difficulty accepting her or his impending death.

1. Sit down quietly next to the bed and allow her or him to cry. Sitting down quietly next to the bed and allowing the client to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her or his feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time the client cries is unimportant at this time. Assuming that the client is having difficulty accepting her or his impending death is a conclusion without enough information.

The nurse is assisting a client to transfer from the bed to a chair. Which would the nurse do to widen her or his base of support during the transfer? 1. Spread his or her feet away from each other. 2. Move the client on the count of three. 3. Tighten the muscles of the internal girdle. 4. Stand close to the client when assisting with the move.

1. Spread his or her feet away from each other. Spreading the feet apart widens the base of support. A wide base of support lowers the center of gravity, thereby increasing stability. Counting to three does not widen the base of support. Counting to three ensures a coordinated effort on behalf of the client and nurse to affect the move, which may alleviate some of the burden borne by the nurse. Flexing the muscles of the internal girdle (contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward) stabilizes the pelvis and protects the abdominal viscera when lifting, pulling, reaching, or stooping, but it does not widen the base of support. Working close to the client is not based on the principle of widening the base of support. This action brings the center of gravity close to the client being moved, permitting the muscles of the nurse's legs and arms to carry the burden of the transfer rather than the muscles of the back.

Which assessment finding is associated with depression? 1. The client has island of intact memory 2. The client has impaired recent and remote memory 3. The client has impaired recent and immediate memory. 4. The client needs step-by-step instructions for simple tasks.

1. The client has island of intact memory. Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.

A client is likely to undergo reconstructive surgery for which purpose? 1. To restore function and/or appearance 2. To replace an organ or tissue 3. To relieve or reduce symptoms 4. To remove or excise an organ or tissue

1. To restore function and/or appearance The main function of reconstructive surgery is to restore function and/or appearance. This type of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In reconstructive surgery, repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known as transplant; surgery to relieve or reduce symptoms is known as palliative; and surgery to remove or excise an organ or tissue is known as resection.

Which intervention reflects the nurse's approach of "family as a context"? 1. Trying to meet the client's comfort 2. Evaluating the client family's coping skills 3. Determining the client family's energy level 4. Trying to meet the client family's nutritional needs

1. Trying to meet the client's comfort In the "family as context" approach, the focus is on the client. The nursing care aims at meeting the client's comfort, hygiene, and nutritional needs. The "family as a client" approach focuses on the family's needs as a whole to determine their coping skills. This approach also includes assessment of the family's energy level to determine if the family would be able to meet the client's needs. In addition, the approach "family as a client" involves assessment of the family's nutritional needs.

At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? 1. Tubing injection port 2. Distal end of the tubing 3. Urinary drainage bag 4. Catheter insertion site

1. Tubing injection port The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse would clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse would apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.

Which type of functional health pattern describes values and goals? 1. Value-belief pattern 2. Role-relationship pattern 3. Self-perception-self-concept pattern 4. Health perception-health management pattern

1. Value-belief pattern The value-belief pattern describes a pattern of values, beliefs, and goals. These guide the client in making choices or decisions. The role-relationship pattern includes the description of the client's patterns in role engagements and relationships. In the self-perception-self-concept pattern, the nurse may describe the client's self-concept pattern and perceptions of self. It involves self-concept/worth, emotional patterns, and body image. The health perception-health management pattern is associated with the description of the client's self-report of health and well-being.

The registered nurse (RN) is evaluating the statements of a new nurse about wound dressings. Which statement made by the new nurse is incorrect? 1. "I should wash my hands with alcohol." 2. "I should use the cotton swab placed on the table." 3. "I should wash my hands before touching the wound." 4. "I should wear gloves before touching the site of injury." Materials used for dressing of wounds must be sterile and free from contamination. The cotton swab placed on the table may not be sterile and if used may cause infections in the client. This statement made by the new orienting nurse indicates the need for further teaching. Alcohol is an antiseptic and can be used to reduce the risk of infections. Clean hands ensure minimum or no risk of infection. Bare hands may be a source of infective organisms; therefore gloves should be worn before touching the site of injury.

2. "I should use the cotton swab placed on the table." Materials used for dressing of wounds must be sterile and free from contamination. The cotton swab placed on the table may not be sterile and if used may cause infections in the client. This statement made by the new orienting nurse indicates the need for further teaching. Alcohol is an antiseptic and can be used to reduce the risk of infections. Clean hands ensure minimum or no risk of infection. Bare hands may be a source of infective organisms; therefore gloves should be worn before touching the site of injury.

When ammonia is excreted by healthy kidneys, which mechanism usually is maintained? 1. Osmotic pressure of the blood 2. Acid-base balance of the body 3. Low bacterial levels in the urine 4. Normal red blood cell production

2. Acid-base balance of the body The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance. Osmotic pressure of the blood and normal red blood cell production are not affected by excretion of ammonia. Ammonia is formed by the decomposition of bacteria in the urine; ammonia excretion is not related to the process and does not control bacterial levels.

Which intervention improves client satisfaction? 1. Recording the vital signs and leaving the room 2. Adjusting the bed and asking if the client is comfortable 3. Leaving the door of the room open while attending to the client 4. Telling the client that the primary health care provider will visit soon

2. Adjusting the bed and asking if the client is comfortable The nurse expresses concern and commitment by adjusting the bed and asking if the client is comfortable. This intervention shows the nurse's willingness to enter into a nurse-client relationship and promotes greater client satisfaction. The client may feel that the nurse is just performing a set of assigned tasks by recording the vital signs and leaving the room. This intervention does not build client satisfaction. The nurse would close the door after entering the room to ensure privacy while providing care. The nurse does not provide effective client satisfaction by informing the client about the primary health care provider's imminent visit.

The registered nurse (RN) teaches the nursing student about the implementation process of nursing. Which example will the RN use to describe indirect care interventions? 1. Counseling the client at the time of grief 2. Administering an intravenous infusion to the client 3. Teaching the client about an appropriate nutrition plan 4. Managing the client's environment to prevent infections Nursing interventions are based on clinical judgment and knowledge and performed by the nurse to enhance the client's outcomes. Indirect care interventions are treatments that are performed away from the client but will benefit the client. Managing the client's environment to prevent infection control is an indirect care intervention. Direct care interventions are performed through interactions with the client. Direct care interventions may include counseling the client at the time of grief, administering an intravenous infusion to the client, and teaching the client about an appropriate nutrition plan.

2. Administering an intravenous infusion to the client Nursing interventions are based on clinical judgment and knowledge and performed by the nurse to enhance the client's outcomes. Indirect care interventions are treatments that are performed away from the client but will benefit the client. Managing the client's environment to prevent infection control is an indirect care intervention. Direct care interventions are performed through interactions with the client. Direct care interventions may include counseling the client at the time of grief, administering an intravenous infusion to the client, and teaching the client about an appropriate nutrition plan.

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? 1. Care that supports physical functioning 2. Care that supports homeostatic regulation 3. Care that supports psychosocial functioning 4. Care that provides immediate short-term help in physiological crises

2. Care that supports homeostatic regulation Providing perioperative care (care before, during, and immediately after surgery) involves care that supports homeostatic regulation. If interventions are provided to support the client in doing daily activities, they are considered a physiological basic domain that supports physical functioning. Providing behavioral and cognitive therapies helps support psychosocial functioning and facilitates lifestyle changes. Providing immediate short-term help in physiological crises helps support protection against harm.

The advanced practice registered nurse (APRN) is caring for a pregnant woman ready to deliver. Which type of APRN would care for this client? 1. Clinical nurse specialist (CNS) 2. Certified nurse midwife (CNM) 3. Certified nurse practitioner (CNP) 4. Certified registered nurse anesthetist (CRNA)

2. Certified nurse midwife (CNM) The CNM is qualified and has the skills to care for a pregnant woman. The CNS is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. The CNP is an APRN who provides health care to a group of clients, usually in an outpatient, ambulatory care, or community-based setting. The CRNA is an APRN with an advanced education in the nurse anesthesia accredited program.

After reviewing a client's reports, the primary health care provider suggests palliative care for the client. Which conditions would qualify the client for this type of care? Select all that apply. One, some, or all responses may be correct. 1. Peptic ulcer 2. Chronic renal failure 3. Cognitive impairment 4. Congestive heart failure 5. Chronic obstructive lung disease

2. Chronic renal failure 4. Congestive heart failure 5. Chronic obstructive lung disease Palliative care aims to minimize client suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce client suffering from the beginning of the therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore these clients do not require palliative care.

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems likely to seek other medical opinions? 1. Anger 2. Denial 3. Bargaining 4. Depression Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.

2. Denial Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events," according to Swanson's theory of caring? 1. Knowing 2. Enabling 3. Doing for 4. Being with

2. Enabling The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process of being with is defined as being emotionally present for someone else.

Which professional standard is important for critical thinking? 1. Logical thinking 2. Evaluation criteria 3. Accurate knowledge 4. Relevant information An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

2. Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Which critical thinking skill refers to the use of knowledge and experience to choose effective strategies for client care? 1. Evaluation 2. Explanation 3. Interpretation 4. Self-regulation

2. Explanation Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.

During a home visit, the nurse finds that a healthy older adult person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. Which inference about the client would the nurse make from these findings? 1. Not motivated 2. Intrinsically motivated 3. Extrinsically motivated with self-determination 4. Extrinsically motivated without self-determination

2. Intrinsically motivated An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy on suggestion or pressure created by other individuals.

When teaching a health promotion class at a retirement home, which information would the nurse include about ways to decrease infection in older adults? 1. Use handkerchiefs. 2. Obtain flu vaccinations. 3. Decrease dietary protein. 4. Limit daily activity.

2. Obtain flu vaccinations. Older adults should obtain regular flu and pneumonia vaccinations to decrease the risk of infection. Disposable tissues should be used instead of handkerchiefs to prevent contamination. Not using disposable tissues leads to reuse of contaminated handkerchiefs. Dietary protein should be increased, and the client should include daily activity because this helps increase immunity.

The nurse changed a dressing on a client's wound with vancomycin-resistant enterococci (VRE). Which step would the nurse take to ensure proper disposal of the soiled dressing? 1. Place the dressing in the bedside trash can. 2. Place the dressing in a red bag/hazardous materials bag. 3. Contact environmental services personnel to pick up the dressing. 4. Transport the dressing to the laboratory to be placed in the incinerator.

2. Place the dressing in a red bag/hazardous materials bag. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; thus the dressing should be placed in a red bag or hazardous materials bag. The soiled dressing should not be placed in a single bag and left in the trash can. Infection control is every health care worker's responsibility, not just environmental services'. The laboratory is not responsible for disposal of hazardous wastes that occur as a result of normal nursing activities.

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is correct when the client becomes short of breath during the care? 1. Obtain a pulse oximeter to determine the client's oxygen saturation level. 2. Put the client in a high Fowler position. 3. Darken the lights and provide a rest period of at least 15 minutes. 4. Continue the hygiene activities while reassuring the client.

2. Put the client in a high Fowler position. Putting the client in the high Fowler position will help expand the lungs and decrease the severity of shortness of breath. Leaving the client to obtain a pulse oximeter while the client is experiencing shortness of breath places the client in danger. Providing a rest period of at least 15 minutes may be appropriate but is not the priority. The nurse needs to acknowledge the change in the client's condition, such as shortness of breath, and take care of this immediate client need before continuing the hygiene activities.

A client with a terminal illness is grateful for the care received in the hospital and has slowly started to come to terms with imminent death. The nurse recognizes that the client's behavior and attitude are most consistent with which cultural group? 1. German culture 2. Somalian culture 3. Ukrainian culture 4. More secular culture

2. Somalian culture Terminally ill clients who belong to the Somalian culture may slowly accept their imminent death and have faith in God. Somalian clients will generally express their gratitude for the care received in the hospital. Clients who belong to the German and Ukrainian cultures may not accept their illness and may fight against the illness in them. Clients who belong to a more secular culture or are less identified by religious institutions may not accept their imminent death.

The new nurse is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. Which answer by the nurse is correct? 1. "Let me get my preceptor." 2. "Wash your hands before and after any client care." 3. "Clean all instruments and work surfaces with an approved disinfectant." 4. "Ensure proper disposal of all items contaminated with blood or body fluids."

2. Wash your hands before and after any client care The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of hand washing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.

Which is the most therapeutic response by the nurse to a client who is joking about dying? 1. "Why are you always laughing?" 2. "Your laughter is a cover for your fear." 3. "Does it help to joke about your illness?" 4. "The person who laughs on the outside cries on the inside."

3. "Does it help to joke about your illness?" The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

The registered nurse (RN) is teaching the nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? 1. "I should serve food that is easy to eat." 2. "I should assist the client with eating." 3. "I should monitor weight and food intake once a month." 4. "I should offer food supplements that are tasty and easy to swallow."

3. "I should monitor weight and food intake once a month." The nurse would monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse would serve food that is easy to eat and provide assistance with eating. The nurse would also offer food supplements that are tasty and easy to swallow.

A home health nurse checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. Which response by the nurse is correct? 1. "I would, but my back hurts today." 2. "Okay. It will be my good deed for the day." 3. "Of course. I want to do whatever I can for you." 4. "I would like to, but it is not in my job description."

3. "Of course. I want to do whatever I can for you." Helping the client meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse would not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. Straightening the blankets is within the nurse's job description.

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" Which is the nurse's most appropriate response? 1. "Do not tell your partner unless asked." 2. "This is a decision you alone can make." 3. "You are having difficulty deciding what to say." 4. "Tell your partner that you don't know how you became sick."

3. "You are having difficulty deciding what to say." The correct response promotes an exploration of the client's dilemma; it encourages further communication. Although the decision is for the client to make, this response is not supportive and abandons the client. It is inappropriate for the nurse to give advice.

The nurse performing a screening test for tuberculosis (TB) explains that which may be the cause of a positive reaction? 1. A depressed immune system 2. An active tuberculosis infection 3. A previous exposure to the organism 4. An imminent tuberculosis infection

3. A previous exposure The presence of antibodies indicates past exposure to or infection with an organism that may be presently dormant. A positive response does not indicate the status of the immune system. A positive response does not necessarily indicate active TB infection; a purified protein derivative (PPD) test administered to an individual with active TB may cause a severe reaction. A positive PPD test does not predict forthcoming exposure or infection; it only indicates past exposure to the organism.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? 1. Red blood cell count 2. Sputum culture 3. Arterial blood gas 4. Total hemoglobin

3. Arterial blood gas Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

The nurse should seek clarification by the practitioner for which order? 1. Discharge in AM 2. Blood glucose monitoring ac and bedtime 3. Erythromycin 250 mg TIW 4. Dalteparin 5000 international units Sub-Q BID

3. Erythromycin 250 mg TIW TIW, indicating three times a week, is an unacceptable abbreviation. It may be mistaken for "three times a day" or "twice weekly." The abbreviation AM for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue." The use of ac (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation Sub-Q, indicating the subcutaneous route, is an acceptable abbreviation. BID, indicating twice a day, is an acceptable abbreviation. International units must be completely spelled out instead of "IU" because it may be mistaken as a roman numeral four (IV).

The nurse is caring for a client who has an implanted port. How often would the nurse change the noncoring needle? 1. Every 3 days 2. Every 5 days 3. Every 7 days 4. Every 9 days

3. Every 7 days Best practice guidelines indicate that noncoring needles be changed at least every 7 days to decrease the risk for infection. Changing a noncoring needle every 3 to 5 days is too frequent and increases the risk for infection as well as client discomfort. Changing a noncoring needle every 9 days increases the risk for infection due to the prolonged length of time the needle is in place.

The nurse keeps track of the immunization schedule for a childbearing family. Which type of nursing care is implemented in this situation? 1. Acute care 2. Home care 3. Health promotion care 4. Restorative and continuing care

3. Health promotion care In family nursing, maintaining adequate prenatal care to a childbearing family and adhering to immunization schedules are performed by the nurse as a part of health promotion. In family nursing, acute care involves preparing family members to assist in health care or in locating appropriate community resources. Investigating medication adherence, neurological issues, and gait and helping clients adapt ways to perform daily activities are interventions performed in home care. In family nursing, restorative and continuing care help maintain a client's functional abilities within the context of the family.

Which are extrinsic factors that determine motivation? Select all that apply. One, some, or all responses may be correct. 1. Fear of failure 2. Educational level 3. Human resources 4. Community systems 5. Accessibility of facilities

3. Human resources 4. Community systems 5. Accessibility of facilities Human resources, community systems, and the accessibility of facilities are extrinsic factors that determine motivation. Characteristics such as fear of failure and the educational level of an individual are intrinsic factors that determine motivation.

Which would the nurse teach the parents of an infant about the use of car seats? 1. Infants should ride in a front-facing car safety seat. 2. Infants should ride in a car safety seat until 1 year of age. 3. Infants should be restrained properly in a federally approved car safety seat. 4. Infants should always ride in a car seat restrained to the front seat of the car.

3. Infants should be restrained properly in a federally approved car safety seat. The nurse would teach the parents to use a federally approved car safety seat to transport the infant. The infant should be properly restrained to the properly installed safety seat. The American Academy of Pediatrics (AAP) requires the infant to ride in a rear-facing car safety seat. The infant should ride in a car safety seat until 2 years of age. The infant should ride in a rear-facing restraint in the front seat of the car only if it does not have a passenger-side air bag.

A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client? 1. It relieves bronchial spasms. 2. It increases the depth of respirations. 3. It loosens pulmonary secretions. 4. It expels carbon dioxide from the lungs.

3. It loosens pulmonary secretions. Postural drainage and percussion, also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

When meeting the preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning? 1. It reduces general anxiety. 2. It is negatively affected by aging. 3. It requires continued reinforcement. 4. It necessitates readiness of the learner.

3. It requires continued reinforcement. Neurological aging causes forgetfulness and slower response time; repetition increases learning. The principle that learning reduces general anxiety is a general principle applicable to all learning. The older adult has no more difficulty learning than a younger person, although it may take longer. The principle that learning necessitates readiness of the learner is a general principle applicable to all learning.

Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)? 1. Insert a urinary catheter 2. Initiate droplet precautions 3. Move the client to a private room 4. Use a high-efficiency particulate air (HEPA) respirator during care.

3. Move the client to a private room. Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, because this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods.

The nurse has provided discharge instructions to a client who received a prescription for a walker. The nurse determines that the teaching has been effective when the client does which? 1. Picks up the walker and carries it for short distances 2. Uses the walker only when someone else is present 3. Moves the walker no more than 12 inches (30.5 cm) during use 4. States that a walker will be purchased on the way home from the hospital

3. Moves the walker no more than 12 inches (30.5 cm) during use Safety is always a consideration when teaching a client how to use an assistive device. The correct procedure regarding using a walker is to move the walker no more than 12 inches (30.5 cm) in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before the client leaves the hospital.

A new mother says to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." From this information, which culture would the nurse infer that the new mother belongs to? 1. Asian culture 2. African culture 3. North American culture 4. Latin American culture

3. North American culture People who belong to North American and Western European cultures generally possess individualistic characteristics. People who belong to Asian, African, and Latin American cultures generally do not possess individualistic characteristics; instead, they have a collectivistic approach. The new mother who belongs to any of these cultures, other than the North American culture, may depend on elder family members for child-rearing.

Which interventions would the nurse perform while caring for an actively dying client? 1. Admit the client in hospice care. 2. Perform aggressive laboratory tests. 3. Provide client and family reassurance. 4. Keep the client undisturbed for a long time. 5. Perform symptom management for the client.

3. Provide client and family reassurance. 5. Perform symptom management for the client. The nurse would provide comfort care in an actively dying client. In comfort care, the nurse would reassure the client and family to reduce their emotional anxiety. The nurse would perform symptom management to improve the client's quality of life. The client should not be admitted into hospice care if he or she is actively dying. A client is admitted to hospice care if death is expected within 6 months. The client may not require aggressive laboratory tests when death is imminent. He or she should be repositioned as needed for comfort.

Which change in the family life-cycle would the nurse advise the young couple planning to start a family to make? 1. Develop intimate peer relationships. 2. Maintain own functions and interests. 3. Realign relationships with extended family. 4. Refocus on midlife material and career issues.

3. Realign relationships with extended family. The nurse informs the young couple that when they take up parenting roles, they will have to realign their relationships with extended family to include grandparenting roles. An individual who is young and unattached will develop intimate peer relationships and begin to differentiate her- or himself from her or his family. Older individuals in later family life start to explore new social roles. These individuals begin to maintain their own functions and interests. Families with adolescents begin to see a shift in the family system. These individuals refocus on midlife material and career issues.

Which definition is involved in the caring process called knowing, according to Swanson's theory of caring? 1. Being emotionally present for the other 2. Sustaining faith in the other's capacity to get through an event 3. Striving to understand an event as it has meaning in the life of the other 4. Facilitating the other's passage through life transitions and unfamiliar events

3. Striving to understand an event as it has meaning in the life of the other In Swanson's theory of the caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other's capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other's passage through life transitions and unfamiliar events is related to the caring process called enabling.

How would the nurse prevent footdrop in a client with a leg cast? 1. Encourage complete bed rest to promote healing of the foot. 2. Place the foot in traction. 3. Support the foot with 90 degrees of flexion. 4. Place an elastic stocking on the foot to provide support.

3. Support the foot with 90 degrees flexion. To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.

A terminally ill client is visited frequently by the spouse and teenage children. Which nursing interventions would the client's plan of care include? 1. Foster self-care by the client whenever possible. 2. Plan care to be completed at one time followed by a long rest. 3. Teach family members how to assist with the client's basic care. 4. Limit visiting to evening hours before the client goes to sleep.

3. Teach family members how to assist with the client's basic care. Because the family members are old enough to understand the client's needs, they should be encouraged to participate in the care. Self-care increases oxygen use, thereby increasing fatigue and dyspnea. Overworking the client causes undue fatigue; there should be frequent rest periods between different aspects of care. Limiting visiting to evening hours deprives the client of a support system.

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the correct response by the nurse? 1. "You must keep up a strong appearance for him." 2. "I think he'd have difficulty dealing with that now." 3. "Don't you think he knows that without you telling him?" 4. "You should share your feelings with him while you can."

4. "You should share your feelings with him while you can." It is difficult to work through a loss; however, encouraging the sharing of feelings helps both parties feel better about having to let go. The response, "You must keep up a strong appearance for him" impedes the work of acceptance of one's finality and the use of the remaining time to the best advantage. There is no evidence to suggest that the client cannot cope with these emotions; the response, "I think he'd have difficulty dealing with that now" denies that this is a time for closeness and honesty. The response, "Don't you think he knows that without you telling him?" is demeaning, closes off communication, and does not foster the expression of feelings.

The nurse would instruct a client with type I diabetes to dispose of a used syringe in which container? 1. Bubble wrap/packaging wrap 2. A garbage bag in the trash can 3. A cardboard box with a firmly secured lid 4. A plastic liquid detergent bottle with a screw-top lid Most states (provinces) allow clients to place used needles/pen needles and lancets (sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque, sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.

4. A plastic liquid detergent bottle with a screw-top lid Most states (provinces) allow clients to place used needles/pen needles and lancets (sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque, sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.

Which critical thinking skill demonstrates maturity in the nurse? 1. Eagerness to acquire knowledge 2. Being tolerant of different views 3. Trust in own reasoning processes 4. Ability to reflect on own judgments

4. Ability to reflect on own judgments Maturity is the ability of a critical thinker to reflect on his or her own judgments. A critical thinker realizes that multiple solutions are acceptable. Inquisitiveness is the eagerness to acquire knowledge. A critical thinker is considered open-minded if he or she respects the right of others to have different opinions and is tolerant of different views. The critical thinker possesses self-confidence and trusts in his or her own reasoning process.

After a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. Which approach would the nurse take when interacting with this client? 1. Explain why there is a need to increase activity. 2. Emphasize that with a prosthesis, there will be a return to the previous lifestyle. 3. Appear cheerful and noncritical regardless of the client's response to attempts at intervention. 4. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

4. Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving. The withdrawal provides time for the client to assimilate what has occurred and to integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

Which is the rationale for the nurse informing the family what is going on with the client? 1. Able to decrease the client's anxiety 2. More relaxed when interacting with the client 3. Less likely to cause problems with the nursing staff 4. Better equipped to undertake necessary family role changes

4. Better equipped to undertake necessary family role changes Early notification provides an opportunity to prepare for change. The ability to decrease the client's anxiety, families being more relaxed, and families being less likely to cause problems with nursing staff may be secondary gains, but are not the primary purpose.

Which activity demonstrates fine motor skills in infants aged 2 to 4 months? 1. Turning from side to back 2. Sitting erect using support 3. Showing good head control 4. Bringing objects from hand to mouth

4. Bringing objects from hand to mouth Bringing objects from hand to mouth indicates a fine motor skill observed in infants aged 2 to 4 months. Turning from side to back, sitting erect using support, and showing good head control are gross-motor skills.

The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explains the analgesic properties of cold therapy? 1. Promoting analgesia and circulation 2. Numbing the nerves and dilating the blood vessels 3. Promoting circulation and reducing muscle spasms 4. Causing local vasoconstriction, preventing edema and muscle spasms

4. Causing local vasoconstriction, preventing edema and muscle spasms Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.

Which safety factor would the nurse teach parents about using a crib for an infant? 1. Ensure the crib has a drop-side rail. 2. Place soft toys and soft pillows inside the crib. 3. Attach toys with hanging strings over the crib. 4. Check that the slats are less than 6 cm (2.4 inches) apart.

4. Check that the slats are less than 6 cm (2.4 inches) apart. If parents are using an older crib, they should check that the slats are less than 6 cm (2.4 inches) apart. The federal safety standard has prohibited the manufacture of cribs with drop-side rails. Parents should avoid using soft mattresses, toys, or pillows inside the crib to reduce the risk for sudden infant death syndrome (SIDS). Toys with hanging strings can lead to accidents. Toys should be attached firmly, without any hanging strings.

The nurse is caring for an older client with arthritis. The nurse uses wooden blocks to elevate the chair legs to help the client sit and stand with little discomfort. Which critical thinking attitude is involved in this situation? 1. Humility 2. Curiosity 3. Integrity 4. Creativity

4. Creativity Creativity is the critical thinking attitude involved in this situation. Creativity involves finding solutions outside of the standard routines of care while maintaining standards of practice. Humility involves admitting any limitations in knowledge and skills. Curiosity involves learning a great deal of information about a client in any critical situation. Integrity involves building trust from your coworkers.

Which pressure change does the nurse determine to be the cause of edema for a client with albuminuria? 1. Decrease in tissue hydrostatic pressure 2. Increase in plasma hydrostatic pressure 3. Increase in tissue colloid osmotic pressure 4. Decrease in plasma colloid oncotic pressure

4. Decrease in plasma colloid oncotic pressure Because the plasma colloid oncotic pressure is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in colloid oncotic pressure caused by albuminuria results in edema. Hydrostatic tissue pressure is unaffected by alteration of protein levels; colloidal pressure is affected. Hydrostatic pressure is influenced by the volume of fluid and the diameter of the blood vessel, not directly by the presence of albumin. The osmotic pressure of tissues is unchanged.

The nurse is reviewing a client's plan of care. Which is the determining factor in the revision of the plan? 1. Time available for care 2. Validity of the problem 3. Method for providing care 4. Effectiveness of the interventions

4. Effectiveness of the interventions When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.

The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on? 1. Teaching how to make a room allergy-free 2. Referring to a support group for individuals with asthma 3. Arranging with the college to ensure a speedy return to classes 4. Evaluating whether the necessary lifestyle changes are understood

4. Evaluating whether the necessary lifestyle changes are understood Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse would change the administration set how often? 1. Every 4 to 8 hours 2. Every 12 to 24 hours 3. Every 24 to 48 hours 4. Every 72 to 96 hours

4. Every 72 to 96 hours Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in clients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.

The nurse plans care for a client who reports anxiety related to uncertainty over the course of recovery. Which action of the client would indicate that the desired goal is achieved? 1. Discusses the surgical outcomes with the surgeon 2. Shares concerns with the spouse before discharge 3. Describes the effects surgery will have on recovery 4. Expresses acceptance of health status by the day of discharge

4. Expresses acceptance of health status by the day of discharge A goal is a desired change in a client's condition or behavior. When a client who is anxious about the disease recovery starts to express acceptance of his or her health status by the day of discharge, it reflects that the desired nursing goal is achieved. The client who shares concerns, describes the effects of surgery on recovery, and discusses surgical outcomes shows partial achievement of the goals (expected outcomes).

Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? 1. Activity theory 2. Continuity theory 3. Disengagement theory 4. Gerotranscendence theory

4. Gerotranscendence theory The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.

Which statement is true about the nursing model of team nursing? 1. The registered nurse (RN) is responsible for all aspects of client care. 2. Client care can be delegated to other members of the health care team. 3. The registered nurse (RN) works directly with the client, family members, and health care team members. 4. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

4. Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In team nursing, there is an existence of hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members. In the nursing model of total client care, the RN is responsible for all aspects of client care; care can be delegated from the RN to other members of the health care team; and the RN works directly with the client, family members, and members of the health care team.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

4. Implementation The basic step of implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, and social culture.

Which nursing process involves delegation and verbal discussion with the health care team? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

4. Implementation The implementation process involves delegation and verbal discussion with the health care team. Planning involves interpersonal or small-group health care team sessions. Evaluation involves the acquisition of verbal and nonverbal feedback. Assessment involves verbal interviewing and talking with clients.

Which action indicates that the nurse is actively listening to the client? 1. Stating personal opinions when the client is speaking 2. Refraining from telling personal stories to the client 3. Reading the client's health record during the conversation 4. Interpreting what the client is saying and restating it for clarification

4. Interpreting what the client is saying and restating it for clarification The nurse is listening actively if what the client says is taken in. The nurse who is listening attentively interprets and reiterates what the client is saying in his or her own words. The nurse who states personal opinions when the client is speaking is being judgmental. A good listener would be able to establish rapport by exchanging personal stories with the client. If the nurse reads the client's health record during the conversation, it is an indication that the nurse is not really interested in the conversation.

The nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? 1. Family in later life 2. Family with adolescents 3. Unattached young adult 4. Launching children and moving on

4. Launching children and moving on The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescence stage of the family life cycle involves establishing flexible boundaries to accommodate the growing child's independence. Individuals experiencing the unattached young adult stage begin to differentiate themselves from their families of origin. The young adult establishes himself or herself at work while the young adult's parents experience the launching children and moving on stage.

Which concept refers to respecting the rights of others? 1. Maturity 2. Systematicity 3. Inquisitiveness 4. Open-mindedness

4. Open-mindedness Open-mindedness refers to respecting the rights of others and being tolerant to of different viewpoints. Maturity refers to reflecting on one's own judgments and having cognitive maturity. Systematicity refers to being organized and focused. Inquisitiveness refers to acquiring knowledge.

Which key factor would the nurse consider when assessing how a client will cope with body image changes? 1. Suddenness of the change 2. Obviousness of the change 3. Extent of the change 4. Perception of the change

4. Perception of the Change It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.

The nurse tries several different ways to communicate with a client after thyroid surgery. Which critical thinking attitude is the nurse demonstrating? 1. Humility 2. Discipline 3. Risk taking 4. Perseverance

4. Perseverance Perseverance is finding effective solutions to problems by trying various approaches. A critical thinker would demonstrate perseverance by not becoming satisfied with the solution unless the solution is near perfect. Humility is accepting one's limitations. Discipline is effective management of time and resources. Risk taking is pushing oneself beyond the limits to find solutions to the problem.

The nurse suspects that a report on a client is incomplete. Which critical thinking attitude is being used when the nurse clarifies information by talking to the client directly? 1. Fairness 2. Humility 3. Discipline 4. Perseverance

4. Perseverance Perseverance requires the nurse to be cautious of an easy answer. If the nurse clarifies some information after talking to the client directly, perseverance has been demonstrated. Fairness requires the nurse to listen to both the sides in any discussion. Humility is associated with recognizing the need for more information when making a decision. When the nurse is thoroughly aware of what is required and manages his or her time effectively, he or she uses discipline.

Which caring intervention helps provide comfort, dignity, respect, and peace to a client? 1. Listening 2. Spiritual caring 3. Providing presence 4. Relieving pain and suffering

4. Relieving pain and suffering Relieving pain and suffering is not just about giving medications but includes providing comfort, dignity, respect, and peace to a client. Listening helps obtain meaningful interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps convey closeness and a sense of caring.

Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? 1. Right task 2. Right person 3. Right supervision 4. Right communication

4. Right communication Right communication refers to the giving of clear and concise descriptions of a task, including its objectives, limits, and expectations, while delegating a task. Right task refers to delegating a task that is repetitive, requires less supervision, and has predictable results. Right person refers to delegating a task to the correct person who has the ability to perform that task. Right supervision refers to providing appropriate monitoring, evaluation, and feedback of the delegated task.

The home health care nurse visits a client who lives with her two grandchildren. Which term would the nurse use to define this family form? 1. Nuclear family 2. Extended family 3. Single-parent family 4. Skip-generation family

4. Skip-generation family A skip-generation family is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of a husband and wife and one or more children. An extended family consists of the nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, or desertion. It may also occur when a single person decides to have or adopt a child.

Which theories are relevant only to development in adults? Select all that apply. One, some, or all responses may be correct. 1. Piaget's theory 2. Erikson's theory 3. Kohlberg's theory 4. Stage-Crisis theory 5. Life Span approach

4. Stage-Crisis theory 5. Life Span approach The Stage-Crisis theory and the Life Span approach are theories related to adult development. Piaget's theory is associated with children's cognitive development. Erikson's theory is associated with psychoanalytical/psychosocial development. Kohlberg's theory is related to moral development.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. Which is it important for the nurse to inform the client of? 1. The client is acting irresponsibly. 2. This action violates the hospital policy. 3. The client must obtain a new primary health care provider for future medical needs. 4. The client must accept full responsibility for possible undesirable outcomes.

4. The client must accept full responsibility for possible undesirable outcomes. The client has the right to self-determination, which includes refusing medical treatment. However, if the client does so, he or she must accept full responsibility for the illness and possible injury or undesirable outcomes. Health care professionals have a responsibility to inform the client and, if possible, have the client sign an informed waiver or a leaving against medical advice document. Acting irresponsibly is a subjective assumption. The client may be violating the hospital policy; however, if the client is deemed competent, he or she has the right to refuse treatment. Leaving against medical advice does not mean that the current primary health care provider will refuse to provide care to the client in the future.

The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client? 1. All nursing functions will be completed by discharge. 2. All invasive intravenous lines will remain patent. 3. The client will remain awake, alert, and oriented at all times. 4. The client will be free of signs and symptoms of infection by discharge.

4. The client will be free of signs and symptoms of infection by discharge. Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.

Which application in practice would best suit the critical thinking attitude of integrity? 1. To look for different approaches 2. To follow the standards of practice in care 3. To always be well prepared before performing a nursing activity 4. To be able to recognize personal opinions that may conflict with a client's opinions

4. To be able to recognize personal opinions that may conflict with a client's opinions Integrity requires the nurse to recognize any personal opinions that may conflict with the opinions of a client. Creativity involves looking for different approaches when standard interventions do not work. The responsible attitude of the nurse requires him or her to follow all the standards of practice in care. Confidence involves being properly prepared before performing a nursing activity.