Master level 1 Fundamentals

The client refuses to receive the recommended treatment after a minor car accident because he believes medical treatment is against his god's wishes. Which type of health belief system is this client adhering to? 1 Folk 2 Holistic 3 Biomedical 4 Alternative or complementary

1 In a folk health belief system, treating illness involves performing rituals or repentance or giving into a supernatural force's wishes. In a holistic health belief system, treating illness involves restoring balance in the physical, social, and metaphysical worlds. In a biomedical health belief system, treatment focuses on the use of physical and chemical interventions. In an alternative or complementary health belief system, treatment may include one or more nonmedical forms such as acupuncture, aromatic therapy, meditation, and therapeutic touch.

The nurse teaches the client to be alert for which common early indication of digoxin toxicity? 1 Nausea 2 Urticaria 3 Photophobia 4 Yellow vision

1 Nausea and loss of appetite are the first indications of toxicity in approximately 50% of clients who take a cardiac glycoside such as digoxin. Urticaria is a rare, not common, manifestation of digoxin toxicity. Photophobia is a later, not early, manifestation of digoxin toxicity. Yellow vision is a later, not early, manifestation of digoxin toxicity.

Which system was implemented through a congressional act that imposed new limits on home health payments? 1 Interim payment system (IPS) 2 Social Security Administration 3 Prospective payment system (PPS) 4 Health maintenance organization (HMO)

1 New limits on home health payments were imposed through a provision of the Balanced Budget Act, called the interim payment system (IPS). The enactment of Title XVIII (known as Medicare) and Title XIX (known as Medicaid) amendments are associated with the Social Security Act. The prospective payment system (PPS) was enacted by Congress as a part of the Tax Equity and Fiscal Responsibility Act. This system pays a set rate based on major diagnostic categories and diagnosis-related groups (DRGs). A health maintenance organization (HMO) is a prepaid health plan that operates independently or through an employer group.

A client who is taking rifampin tells the nurse, "My urine looks orange." Which nursing action would the nurse take? 1 Explain that this is expected. 2 Check the liver enzymes. 3 Strain the urine for stones. 4 Ask what foods were eaten.

1 Rifampin causes a reddish-orange discoloration of secretions such as urine, sweat, and tears. Although liver enzymes should be monitored because of the risk of hepatitis, this action is not addressing the client's statement. Straining the urine for stones is indicated for renal calculi, which are not related to rifampin. The medication, not food, is responsible for the urine color.

During the immune response, which factor leads to chronic inflammation and damage to the host tissue? 1 Regulation of action 2 Remembering the invader 3 Responding to nonself invaders 4 Recognition of the self from nonself

1 Self-regulation allows the immune system to manage itself by "turning on" when an antigen invades and "turning off" when the invasion has been destroyed. If a cell is unable to regulate, it may cause chronic inflammation and tissue damage. Remembering the invader is necessary when the same antigen that invaded in the past attacks again. This action allows for a quicker immune response. The immune response that involves recognizing the self from the nonself is crucial because the body recognizes its own cells and does not produce antibodies against them. The immune response involving the response to nonself invaders occurs via the release of antibodies that target specific antigens for destruction.

Which action would the nurse take to widen the client's base of support during a transfer from the bed to a chair? 1 Spread the client's feet away from each other. 2 Move the client on the count of three. 3 Instruct the client to flex the muscles of the internal girdle. 4 Stand close to the client when assisting with the move.

1 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 nursing action takes priority for a scorpion sting? 1 Assessing the client's vital signs 2 Applying an ice pack to the sting site 3 Contacting the poison control center 4 Covering the client with cooling blanket

1 The first priority is vital sign assessment for a client who sustained a scorpion sting. Continuous monitoring for several hours in the critical care unit helps to ensure the client's safety. The nurse has to then apply an ice pack to the sting site to reduce pain. The poison control center assists with client management, particularly in regard to the use of medications for scorpion stings, and this is a medium priority. Covering the client with a cooling blanket to reduce fever is of lowest priority.

Which is the best response by the nurse when the spouse of a client with heart failure voices concern about how pale the client seems? 1 "You must be frightened by this." 2 "Paleness is expected with heart problems." 3 "Other people get pale and recover without any complications." 4 "I can understand why you are worried, but your spouse will be alright."

1 The response "You must be frightened by this" addresses the spouse's concerns and encourages further verbalization of feelings. The response "Paleness is expected with heart problems" does not focus on the spouse's underlying concerns and keeps the discussion on a physiologic level. The responses "Other people get pale and recover without any complications" and "I can understand why you are worried, but your spouse will be alright" provide false reassurance and cut off further verbalization of feelings.

After completing a delegated task, which action by the unlicensed nursing personnel demonstrates individual accountability? Select all that apply. One, some, or all responses may be correct. 1 Taking full responsibility for the action performed 2 Ensuring that the task has achieved the desired outcome 3 Ensuring that others on the unit are completing their tasks 4 Establishing systems for assessing and monitoring the tasks assigned 5 Evaluating whether the work environment is conducive to work

1, 2 Individual accountability is a component of delegation. It refers to the individual's ability to take responsibility for the actions performed and the outcomes related to the task. Ensuring that others are doing their tasks, establishing systems for assessing and monitoring the competencies, and evaluating whether the work environment is conducive to work are all related to organizational accountability, not individual accountability.

Which statements about family violence indicate a need for further teaching? Select all that apply. One, some, or all responses may be correct. 1 It occurs only in certain social classes. 2 Poverty is a contributing factor. 3 Social isolation decreases the risk. 4 It is associated with negative long-term physical consequences. 5 Pregnancy may increase the incidence.

1, 3 Family violence occurs across social classes, not just in certain ones. Social isolation increases, not decreases, the risk for family violence. These statements indicate a need for further teaching. The others are correct. Poverty is a contributing factor to family violence. Family violence is also associated with negative long-term physical and emotional consequences. Pregnancy may increase the incidence of violence within a family.

Which clinical finding would a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1 Rapid, thready pulse 2 Distended jugular veins 3 Elevated hematocrit level 4 Increased serum sodium level

2 Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

Which statement about preferred provider organizations (PPOs) is correct? 1 The goal of a PPO is to keep clients healthy. 2 PPOs offer a discount on fees in return for a large pool of potential clients. 3 The two national PPOs are Kaiser Permanente and U.S. Family Health Plan. 4 The number of health care providers is more limited in PPOs than in health maintenance organizations (HMOs).

2 PPOs offer a discount on fees in return for a large pool of potential clients. The goal of the HMO is to keep all clients healthy. The two national HMOs are Kaiser Permanente and U.S. Family Health Plan. A PPO has a larger number of physicians than an HMO.

Which instructions would the nurse include when providing preoperative teaching for a client regarding the use of an incentive spirometer? 1 "Inhale completely and exhale in short, rapid breaths." 2 "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." 3 "Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." 4 "Exhale halfway, then inhale a rapid, small breath; repeat several times."

2 The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer, and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery. Exhaling halfway, then inhaling a rapid, small breath and repeating several times is a completely inaccurate procedure for using an incentive spirometer. Inhaling completely and exhaling in short, rapid breaths is a completely inaccurate procedure for using an incentive spirometer. Exhaling completely and then taking a slow, deep breath; holding it as long as possible; and slowly exhaling is partially correct but does not state to use the incentive spirometer. When teaching clients, it is important to provide exact step-by-step instructions, thus, not leaving out any critical points.

A client who is to have sclerotherapy asks the nurse, "How did I get varicose veins?" Which etiology would the nurse take into consideration when formulating a response? 1 Short episodes of standing 2 Defective valves within the veins 3 Compression of leg muscles on the veins 4 Formation of thrombophlebitis in the veins

2 Varicose veins are dilated veins that occur as a result of incompetent valves. Varicosities may result from heredity factors, prolonged standing (which puts strain on the valves), and abdominal pressure on the large veins of the lower abdomen as occurs during pregnancy. Prolonged standing increases pressure on the valves within the veins. Compression of leg muscles on the veins limits venous pooling. Varicose veins increase the risk for thrombophlebitis; thrombophlebitis does not cause varicose veins.

While assessing the body temperature of a client, the nurse finds the client has a subnormal temperature. Which intervention is beneficial for the client? 1 Administering acetaminophen 2 Covering the client with blankets 3 Assessing for a headache, thirst, and chills 4 Assessing for a possible site of localized infection

2 When a client's temperature is subnormal, the nurse should cover the client with more blankets. Acetaminophen is not appropriate for a subnormal temperature; it is appropriate for an elevated temperature. If the client's temperature is elevated, the nurse should further assess for a headache, thirst, and chills. When the client's temperature is above normal, the nurse should assess for a possible site of infection.

The registered nurse is discussing with a licensed practical nurse (LPN) how to communicate with a client with hearing loss. Which statement made by the LPN indicates a need for further discussion? 1 "I will face the client with my mouth visible to the client." 2 "I will provide a sign language interpreter to communicate." 3 "I will rephrase the sentence if the client misunderstands it." 4 "I will reduce any environmental noise while communicating."

2 When planning with the registered nurse, the LPN should find out how extensive the client's hearing loss is. A sign language interpreter may not be necessary. However, the LPN's other statements are appropriate for a client with hearing loss: The nurse should face the client with his or her mouth visible to the client. The nurse should rephrase the sentence rather than repeating it if the client misunderstood the first time. The nurse should reduce any environmental noise while communicating.

A hospital wants to implement the primary nursing model on the premises. Which challenge is likely to be faced by the management? Select all that apply. One, some, or all responses may be correct. 1 Lack of client rapport 2 Lack of nurse availability 3 Lack of experienced nurses 4 Decrease in cost for management 5 Lack of communication with health care providers

2, 3 In the primary nursing model, a single nurse cares for a client while that client is in the hospital. This model requires a nurse to be available 24 hours a day, but it is not possible for any nurse to work for that whole period. A nurse may not be specialized in all fields and may not have enough experience to care for all types of clients; this may become a challenge for management. If a single nurse cares for a client, that client may be more comfortable, which will increase client rapport. This model becomes more costly because a nurse may charge more for working so many hours for a client. In this model there will be increased communication with the health care provider; this may be an advantage for management.

Which nursing intervention requires a nurse to wear gloves? Select all that apply. One, some, or all responses may be correct. 1 Giving a back rub 2 Cleaning a newborn immediately after delivery 3 Emptying a portable wound drainage system 4 Interviewing a client in the emergency department 5 Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

2, 3 Personal protective equipment (PPE) should be used because the newborn is covered with amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub; there is no indication that the nurse is in contact with bodily secretions. PPE is not necessary when conducting an interview because it is unlikely that the nurse will come into contact with the client's body fluids. PPE is not necessary when obtaining the blood pressure of a client, even if the client is HIV positive.

Which statement is true regarding the right supervision aspect of delegation? Select all that apply. One, some, or all responses may be correct. 1 It includes limits and expectations. 2 It is essential to maintain accountability. 3 It is essential to complete the task in time. 4 It involves providing assistance and feedback. 5 It includes the appropriate client setting and available resources.

2, 3, 4 Right supervision is essential to maintaining accountability of events taking place while delegating a task and completing a task in a timely manner. It is essential for the delegatee to ask questions and seek assistance comfortably and for the delegator to provide appropriate feedback. Right communication involves limits and expectations. Right circumstances include figuring out the appropriate client setting and available resources.

Which client history would the nurse recognize as a possible cause of mitral valve stenosis? 1 Cystitis as an adult 2 Pleurisy as an adult 3 Childhood strep throat 4 Childhood German measles

3 Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered, damaging the heart. Cystitis usually is caused by Escherichia coli, which does not affect heart valves. Pleurisy usually follows pulmonary problems unrelated to streptococcal infection; it does not result in damage to heart valves. The rubella virus does affect the valves of the heart.

Which would the nurse refer to in order to understand the new standards for education and competency evaluation under the new Medicare rules? 1 Social Security Act 2 Prospective payment system 3 The Omnibus Budget Reconciliation Act 4 The Health Care Financing Administration

3 The Omnibus Budget Reconciliation Act involves formulation of new standards for training and competency evaluation. The Social Security Act includes Medicare and Medicaid amendments. The Prospective payment system provides incentives to primary health care providers to be more efficient in providing home health care. The Health Care Financing Administration aims to receive claims for payment and to process reimbursement.

Which client statement indicates a need for further instruction/clarification about the risk for influenza A (H1N1) transmission to others? 1 "I should practice respiratory hygiene/cough etiquette." 2 "I should avoid contact with older adults or children." 3 "I should obtain a pneumococcal vaccination each year." 4 "I should allow visitors for short periods of time only."

3 The client should be encouraged to receive an influenza vaccine each year. Pneumococcal vaccines will not prevent influenza. The nurse should stress the importance of practicing respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable populations such as older adults and children. Visitors for clients in isolation for influenza should be limited to persons who are necessary for the client's emotional well-being and care. Visitors who have been in contact with the client before and during hospitalization are a possible source of influenza for other clients, visitors, and staff.

Which type of health care organization is appropriate for a client who is unable to meet his or her daily needs independently related to a psychological disability? 1 Day care facility 2 Respite care facility 3 Long-term care facility 4 Home health care facility

3 The goal of a long-term care facility is to keep clients as independent as possible. The need for long-term care arises when an individual is incapable of meeting the daily needs of living because of a physical or psychological impairment; this type of facility is most appropriate for this client. A day care facility is a setting that provides structured age-appropriate activities during the day; this is frequently used by family members and caregivers who work during the day. Respite care provides temporary relief to caregivers and is often part of a home health care program rather than a separate facility. Home health care brings professional care to the client's home.

Which realm of family life processes is the nurse trying to assess when the nurse asks what the family does for relaxation? 1 Health 2 Integrity 3 Interactive 4 Developmental processes

3 The nurse would ask family members what they do to relax to assess their use of leisure time, which is an interactive process. Health, integrity, and developmental processes encompass other aspects of family life.

Which health care organization has recently focused on promoting the need for changes in the nursing work force? 1 Institute of Medicine 2 American Red Cross 3 National Federation of Licensed Practical Nurses 4 American Nurses Association

1 The Institute of Medicine recently established a focus on promoting the need for changes in the nursing work force, including the goal of 80% of working nurses to be baccalaureate degree-prepared. The American Red Cross is a volunteer organization with less of a focus on the nursing work force. The National Federation of Licensed Practical Nurses and the American Nurses Association have goals that are focused more on nursing education and less on the nursing work force.

The registered nurse (RN) delegates a task to the licensed practical nurse (LPN). If the LPN fails to perform the task within acceptable standards, which would happen? Select all that apply. One, some, or all responses may be correct. 1 A potential for nursing malpractice emerges. 2 The institution remains legally responsible for the situation. 3 The accountability for care remains with the RN. 4 The licensure of the LPN would be revoked. 5 The accountability for care remains with the LPN.

1, 2, 3 If the delegated task is not performed within acceptable standards, a potential for nursing malpractice emerges. Failure to delegate and supervise within acceptable standards may extend to direct corporate liability for the institution. Whenever care is provided by staff other than an RN, the accountability for care remains with the delegator who is an RN. The licensure of the LPN would not be revoked because the LPN is not held accountable for the situation. When the work is assigned to the LPN, only responsibility of the task is transferred.

Which characteristic would a holistic health belief system exhibit? Select all that apply. One, some, or all responses may be correct. 1 Circumcision is considered a religious practice. 2 Rituals and repentance comprise treatment. 3 Animate or inanimate objects may have healing powers. 4 Physical and chemical interventions comprise treatment. 5 Humans can manipulate life processes with mechanical interventions.

1, 3 In a holistic health belief system, religious experiences are based on cultural beliefs. Therefore, a ritual like circumcision is viewed as a religious, not medical, practice, and animate or inanimate objects may have healing powers. In a folk health belief system, not a holistic one, treatment involves rituals and repentance. In a biomedical health belief system, not a holistic one, physical and chemical interventions comprise treatment, and humans can manipulate life processes with mechanical interventions.

A nurse administers an intramuscular analgesic against the will of a terminally ill client. Which crime would the nurse be charged with in this situation? 1 Assault 2 Battery 3 Invasion of privacy 4 Lack of informed consent

2 Battery is the intentional touching of one person by another without permission of the person being touched. Assault is an intentional act without touching that makes a person fearful or produces reasonable apprehension of bodily harm. Invasion of privacy refers to abusing the right of clients to have their private affairs protected. Informed consent applies to permission for procedures and treatments to be performed.

Which information would the nurse consider when planning care for a client with hypertension that is related to atherosclerosis? 1 Renin causes a gradual decrease in arterial pressure. 2 Lipid plaque formation occurs within the arterial vessels. 3 Development of atheromas within the myocardium is characteristic. 4 Mobilization of free fatty acid from adipose tissue contributes to plaque formation.

2 The term atherosclerosis means a thickening of the arterial lining by lipid plaques, which become atheromas. Arterial pressure increases, not decreases, as a result of renin. Atheromas develop within the lining of the arteries, not within the cardiac muscle tissue. Mobilization of free fatty acids will produce an acid-base imbalance.

Which health belief system is being applied when the family member of a client with depression believes the client would benefit from aromatic therapy, more so than from medications? 1 Folk health 2 Holistic health 3 Biomedical health 4 Alternative or complementary health

4 A client who opts for nonmedical treatment methods such as aromatic therapy probably has an alternative or complementary health belief system. In a folk health belief system, rituals or repentance may be used to treat the client. In a holistic health belief system, the client's family would look for ways to restore balance in the physical, social, and metaphysical worlds surrounding the client. A family member who believes in biomedical treatment would accept the medications for the client.

Which finding would the nurse in the postanesthesia care unit report to the primary health care provider about a client who received a general anesthetic? 1 Client pushes the artificial airway out. 2 Client has snoring respirations. 3 Client's respirations are 16 breaths per minute and shallow. 4 Client's systolic blood pressure drops from 130 to 90 mm Hg.

4 A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are all signs of decreased blood volume and shock, which if not treated promptly can lead to death. Any of these findings would be reported to the provider. The client pushing the artificial airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Shallow respirations of 16 breaths per minute and snoring respirations are common responses to the depressant effects of anesthesia.

Which action would the nurse take initially when obtaining consent for surgery? 1 Describing the risks involved in the surgery 2 Explaining that obtaining the signature is routine for any surgery 3 Witnessing the client's signature, which the nurse's signature will document 4 Determining whether the client's knowledge level is sufficient to give consent

4 Informed consent means the client must comprehend the surgery, the alternatives, and the consequences. Describing the risks involved in the surgery is not within nursing's domain. Although obtaining a signature is routine, explaining that obtaining the signature is routine for any surgery does not determine the client's ability to give informed consent. Although witnessing the client's signature would be done, the nurse first would assess the client's knowledge of the surgery.

Which task is most appropriate for a nurse to delegate to unlicensed assistive personnel (UAP)? 1 Emptying a portable wound drainage device 2 Instructing a client to use an incentive spirometer 3 Monitoring the rate of infusion of intravenous fluids 4 Taking the blood pressure of a client before physical therapy

4 Taking vital signs is an appropriate task to delegate to UAP; it is within their job description because it is a task that has manageable parameters. Emptying a portable wound drainage device involves surgical asepsis; it is not an appropriate task to delegate to UAP. Client education is not an appropriate task to delegate to UAP; it requires the education achieved by a professional nurse. Monitoring infusion rates involves an invasive line; this is not an appropriate task to delegate to UAP.

Which client statement indicates an understanding of the nurse's instructions regarding a Holter monitor? 1 "The only times the monitor should be taken off is for showering and sleep." 2 "The monitor will record my activities and symptoms if an abnormal rhythm occurs." 3 "The results from the monitor will be used to determine the size and shape of my heart." 4 "The monitor will record any abnormal heart rhythms while I go about my usual activities."

4 The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.

Which statement is an example of an intermediate priority need? 1 The teachings of home self-care 2 A psychological episode of an anxiety attack 3 A physiologic episode of an obstructed airway 4 The measures required to decrease postoperative complications

4 The nurse leader should have the ability to set the priorities of the client depending on the client's need. Intermediate priority needs include nonemergency, nonlife-threatening needs. An example of this need would be measures that are required to decrease postoperative complications. The teaching of home self-care is a low priority need. High priority needs include addressing a psychological episode of an anxiety attack and addressing a physiologic episode of an obstructed airway.

Which collaborative intervention can the nurse perform to help relieve a client's nausea after cataract surgery? 1 Administer the prescribed antiemetic drug. 2 Provide some dry crackers for the client to eat. 3 Explain that this is expected following surgery. 4 Teach how to breathe deeply until the nausea subsides.

1 An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Providing some dry crackers for the client to eat, explaining that this is expected following surgery, and teaching how to breathe deeply until the nausea subsides are unsafe; vomiting increases intraocular pressure, and aggressive intervention is required.

Which function is related to skeletal muscle? Select all that apply. One, some, or all responses may be correct. 1 Eye movements 2 Movement of bones 3 Contraction of the heart 4 Changing the diameter of the pupils 5 Movement of substances along ducts

1, 2 The skeletal muscles help in eye and bone movements. Cardiac muscles help in contraction of the heart. The smooth muscles change the diameter of the pupils and help in the movement of substances along the ducts.

Which statement made by the newly hired nurse indicates understanding about communication when delegating tasks? Select all that apply. One, some, or all responses may be correct. 1 "I will keep the information simple." 2 "I will share more information than required." 3 "I will share the information using the electronic health record." 4 "I will provide an opportunity to clarify the information." 5 "I will repeat the information in the same way until the new nurse understands it."

1, 3, 4 While communicating with the delegatee, the information should be simple to enable better understanding. Electronic health records are used as a primary communication mechanism to share information. Providing an opportunity to clarify the information helps evaluate the ability of the delegatee. Giving more information than required may lead to confusion. The information should be repeated in different ways if necessary to ensure better understanding.

A nursing instructor explains to nursing students how ethnic stereotyping can be detrimental and affect the care of a client. Which comment from the nursing students demonstrates the need for further teaching? Select all that apply. One, some, or all responses may be correct. 1 "I should treat all clients the same to provide effective care." 2 "The health beliefs of my culture are the most helpful for the client." 3 "Some cultures are prone to violence and have criminal tendencies." 4 "Understanding client's health practices can be valuable and increase compliance." 5 "Clients from different parts of the world are less compliant with Western medicine."

1, 3, 5

Which source of funding would support a visiting nurse association that is providing public health services under the governance of a community-based board of directors? Select all that apply. One, some, or all responses may be correct. 1 Grants 2 County revenues 3 Fees from all sources 4 Charitable contributions 5 Tax-deductible contributions

1, 3, 5 A visiting nurse association is an example of a voluntary home health agency, and it is governed by a community board of directors. Voluntary home health agencies are supported by grants, fees from all sources, and tax-deductible contributions. County revenues and charitable contributions support official and combination home health agencies but not voluntary home health agencies.

Which finding would a nurse expect in a client who was in a car accident and whose parasympathetic system has now returned the body to baseline? Select all that apply. One, some, or all responses may be correct. 1 Decreased heart rate 2 Bronchodilation 3 Pupillary dilation 4 Normal blood pressure 5 Decreased gastrointestinal motility

1, 4 The parasympathetic response decreases heart rate and returns blood pressure to normal. Bronchodilation, pupillary dilation, and decreased gastrointestinal motility are associated with the sympathetic response.

The public health nurse is leading a workshop for families on personal disaster preparedness in the community. Which information would be included for the families? Select all that apply. One, some, or all responses may be correct. 1 Electric blankets 2 Nonperishable food 3 Vehicle (full gas tank) 4 Cell phone and charger Correct 5 Flashlight with batteries

1, 4, 5 When putting together basic supplies for a personal preparedness kit, the nurse will instruct families to include nonperishable food, a cell phone and charger, and flashlights with batteries. Electric blankets will not work if electric power is affected. A vehicle will not necessarily be useful as roads may or may not be passable after a disaster.

Which aspect relates to the quality of relationships while assessing the degree of conflict resolution in nursing leadership? Select all that apply. One, some, or all responses may be correct. 1 Creativity of the plan 2 Generation of empathy 3 Practicality of the objectives 4 Understanding being created 5 Wellness of the intended goals achieved

2, 4 Quality of relationships includes aspects such as generation of empathy and the understanding being created. The aspects of the creativity of the plan, practicality of the objectives, and wellness of the intended goals achieved relate to the quality of decisions.

Which statement about active transport is true? Select all that apply. One, some, or all responses may be correct. 1 Active transport requires energy expenditure. 2 Active transport begins the formation of urine. 3 Active transport helps provide sodium ions to nerve cells. 4 Active transport helps move carbon dioxide out of all cells. 5 Active transport involves the trapping of bacterial cells through phagocytosis.

1, 5 Active transport requires energy and helps trap bacterial cells through phagocytosis. Passive transport begins the formation of urine. Passive transport helps provide sodium ions to nerve cells. Passive transport helps move carbon dioxide out of all cells.

Which source of funding would a county-based visiting nurse association receive if it is governed by a community-based board of directors and volunteer board of representatives? Select all that apply. One, some, or all responses may be correct. 1 Grants 2 State revenues 3 Fees from all sources 4 Charitable contributions 5 Tax-deductible contributions

1. 2. 4 A county-based visiting nurse association governed by a community-based board of directors and a volunteer board of representatives is an example of a combination health agency. This agency receives support from grants, state revenues, and charitable contributions. A hospital-based agency receives fees from all sources. A voluntary health agency receives support from tax-deductible contributions.

Which food that produces a large amount of gas would the nurse instruct a client with a new colostomy to avoid? 1 Milk 2 Cheese 3 Coffee 4 Cabbage

4 Cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage. Milk, cheese, and coffee, in moderation, should not cause excessive gas problems. The client with a new colostomy should slowly introduce new foods into the diet to test toleration.

Which treatment does the nurse expect the plan of care will include for a client diagnosed with multiple myeloma? 1 Radiotherapy on an outpatient basis 2 Human leukocyte interferon therapy 3 Surgery to remove the invasive lesions 4 Chemotherapy employing a combination of drugs

4 Chemotherapy employing a combination of drugs is the treatment of choice; a variety of chemotherapeutic drugs affect rapidly dividing cells at different stages of cell division. Although radiotherapy on an outpatient basis may be used to alleviate pain and treat acute vertebral lesions, it is not the primary approach. Although human leukocyte interferon therapy may be done, it is not the primary treatment. Multiple myeloma is a diffuse disorder of the bone, and no single lesion can be removed.

Which symptom would the client notify the health care provider about after receiving education about hydrochlorothiazide? 1 Insomnia 2 Nasal congestion 3 Increased thirst 4 Generalized weakness G

4 Generalized weakness is a symptom of significant hypokalemia, which may be a sequela of diuretic therapy. Insomnia is not known to be related to hypokalemia or hydrochlorothiazide therapy. Although a stuffy nose is unrelated to hydrochlorothiazide therapy, it can occur with other antihypertensive drugs. Increased thirst is associated with hypernatremia. Because this drug increases excretion of water and sodium in addition to potassium and chloride, hyponatremia, not hypernatremia, may occur.

Which is a component of the primary survey? 1 Disability 2 Abdomen and flanks 3 Head, neck, and face 4 History of the illness or injury

1 Assessing disability by conducting a brief neurologic examination is a component of the primary survey, which aims to identify life-threatening conditions so appropriate interventions can be started. Assessment of the abdomen and flanks; the head, neck, and face; and the history of the illness or injury are all part of the secondary survey, which begins after addressing each step of the primary survey and starting any lifesaving interventions.

Which system has guidelines that include provision of physical assistance only 2 hours per day? 1 Medicare 2 Third party 3 Private pay 4 Preferred provider organization

1 For Medicare, aide services are provided in blocks of time ranging from 1 to 2 hours. Third party, private party, and preferred provider organizations may allow a provision of services for 8 to 24 hours.

Which instruction would the nurse provide to the client to promote sleep? Select all that apply. One, some, or all responses may be correct. 1 "Include meat in your diet." 2 "Drink milk before going to sleep." 3 "Avoid including cheese in your diet." 4 "Regularly change your daily routine." 5 "Perform moderate exercise 2 hours before bedtime."

1, 2, 5 To promote sleep, the nurse should instruct the client to include meat in his or her diet and to drink milk before going to sleep. These foods help induce sleep. The nurse should also instruct the client to perform moderate exercise 2 hours before bedtime; the time between exercise and bedtime allows the body to cool down and promotes relaxation. The nurse should instruct the client to avoid often changing the daily routine, which can disrupt sleep patterns. The nurse should instruct the client to include, not exclude, cheese in the diet because it induces sleep.

Which information would a nurse give to a client who has been referred to a physical therapist? Select all that apply. One, some, or all responses may be correct. 1 Physical therapy may help regain function. 2 Family members are not included in the process. 3 The goal of physical therapy is to maintain function. 4 An evaluation by the physical therapist must be done. 5 Physical therapy is prescribed after periods of immobilization.

1, 3, 4, 5 Physical therapy can help clients with prolonged periods of immobilization to maintain and regain function. It begins with an initial evaluation and may include family members in the process.

Which intervention would the nurse implement when caring for a dying client and family? Select all that apply. One, some, or all responses may be correct. 1 Arrange for restorative care. 2 Help the family set up hospice if desired. 3 Refrain from telling the family that the client is dying. 4 Plan care using the client and family's strengths and weaknesses. 5 Arrange for church or community support for the family.

2, 4, 5 Some dying clients prefer to be at home with the family during their last days. The nurse should help the family set up hospice if desired. The nurse should know the client and family well to be able to provide patient-centered care. The nurse should arrange for church or community support to help the client and family during this difficult time. A dying client may be in pain and require hospice care, not restorative care. The nurse must maintain the trust in the nurse-client relationship and prepare the family for the client's death. The nurse should inform the family about the dying process.

Which quality of a leader indicates a transformational approach to leadership? Select all that apply. One, some, or all responses may be correct. 1 Punitive in nature 2 Charismatic 3 Contingent reward 4 Intellectually stimulating 5 Inspirational and motivational

2, 4, 5 The leader who has a transformational approach to leadership possesses charismatic, intellectually stimulating, and inspirational and motivational qualities. The transformational leader follows an inspirational and motivational approach. The leader who uses the transactional leadership approach has a punitive nature and gives rewards to followers contingently.

Which type of freestanding home health agency receives support from some sources that participate in Medicare-Medicaid and some that do not? 1 Official 2 Voluntary 3 Proprietary 4 Combination

3 A proprietary home health agency is freestanding and receives support from sources that may or may not participate in Medicare-Medicaid. An official home health agency receives support from local government, grants, fees from limited sources, and charitable contributions. A voluntary home health care agency receives support from tax-deductible contributions, grants, and fees. A combination home health care agency receives support from local government revenues, grants, fees from limited sources, and charitable contributions.

Which laboratory test would the nurse monitor to evaluate hypoxia in a client with chronic obstructive pulmonary disease? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin

3 All of these laboratory 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.

Which nursing action is most appropriate to reduce falls in older adults in the hospital? Incorrect 1 Moving the client's bedside table closer to the bed 2 Encouraging the client to take an available sedative 3 Instructing the client to call the nurse before going to the bathroom 4 Assisting the client to telephone home to say goodnight to the spouse

3 Statistics indicate that the most frequent cause of falls in hospitalized clients is getting up or attempting to get up to use the bathroom unassisted. Although moving the bedside table closer to the bed would be helpful in reducing falls because it moves the bedside table closer to the client's center of gravity, it is not the primary intervention to prevent falls. Sedatives contribute to the risk for falls by altering the client's sensorial abilities. Although talking to the spouse may calm the client and contribute to sleep, it would not reduce the incidence of falls.

To which religious group would the parents of a newborn belong if the nurse observes an ordained priest moving the infant in the air in the sign of the cross? 1 Muslim 2 Mennonite 3 Presbyterian 4 Eastern Orthodox

4 Eastern Orthodox babies are required to be baptized within 40 days after birth. If sprinkling or immersion into water is not possible, an ordained priest can perform the baptism by moving the infant in the air in the sign of the cross. Muslim and Mennonite infants are not baptized. Presbyterian infants are baptized with pouring or sprinkling water.

To which religious group does a client who does not eat pork, cornbread, or collard greens most likely belong? 1 Baptist 2 Roman Catholic 3 Eastern Orthodox 4 American Muslim Mission

4 Individuals belonging to the American Muslim Mission do not consume pork, and many also refrain from eating foods that are traditional in African American culture, such as cornbread and collard greens. Baptists practice total abstinence from alcohol but have no restrictions against pork, cornbread, or collard greens. Roman Catholic individuals do not eat meat on the Wednesday of the beginning of Lent, and Fridays during lent; but they can eat meat on all other days. Individuals belonging to the Eastern Orthodox Church fast from meat and dairy products on Wednesdays and Fridays during Lent and on other holy days; fasting is not mandatory for hospital clients.

Which substance will the home health nurse instruct a client to use after laryngectomy to cleanse the stoma site? 1 Sterile saline 2 Steroid cream 3 Oil-based lubricant 4 Mild soap and water

4 Mild soap and water are used to cleanse the stoma site. Sterile saline, a humidifier, or pans of water can be used to humidify the air entering the stoma. There is no need to use steroid cream at the site unless instructed by the health care provider. Non-oil-based, rather than oil-based, lubricants can be used as needed for lubrication of the site.

Which indicator would the nurse use to determine effectiveness after administration of sublingual nitroglycerin? 1 Relief of anginal pain 2 Improved cardiac output 3 Decreased blood pressure 4 Dilation of superficial blood vessels C

1 Cardiac nitrates relax smooth muscles of the coronary arteries. They dilate and deliver more blood to heart muscle leading to relief of ischemic pain. Cardiac output may improve because of improved oxygenation of the myocardium, but improved cardiac output is not a basis for evaluating the drug's effectiveness. Dilation of blood vessels and a subsequent drop in blood pressure may occur, but decreased blood pressure is not a basis for evaluating the drug's effectiveness. Superficial vessels dilate and lower the blood pressure creating a flushed appearance, but dilation of superficial blood vessels is not a basis for evaluating the drug's effectiveness.

Which type of abuse describes what a nurse would suspect when a mother reports that her 5-year-old girl has genital discharge and recurrent urinary tract infections? 1 Sexual abuse 2 Physical abuse 3 Physical neglect 4 Emotional neglect

1 Genital discharge and recurrent urinary tract infections are signs of sexual abuse. Bruises, burns, fractures, or dislocation may indicate physical abuse. Malnutrition and poor hygiene may indicate physical neglect. Enuresis and sleep disorders may indicate emotional neglect.

When discussing family planning, a client tells the nurse: "Though our law permits contraception, we are not encouraged to use contraceptives as it interferes with Allah's will. I am also not allowed to have an abortion." To which religious group does the client belong? 1 Islam 2 Mormon 3 Roman Catholic 4 Eastern Orthodox

1 In Islam, women may use contraception, but it is not encouraged. They are not allowed to have an abortion. Mormons are only supposed to use natural means of birth control unless pregnancy would jeopardize the mother's well-being. Roman Catholics only use contraception in the form of abstinence and natural family planning. Eastern Orthodox members are not allowed any birth control.

Which information is important for the nurse to use when administering potassium chloride intravenously to a client? 1 Oliguria is an indication for withholding intravenous (IV) potassium. 2 Rapid infusion of potassium prevents burning at the IV site. 3 Clients with severe deficits should be given IV push potassium. 4 Average IV dosage of potassium should not exceed 60 mEq in 1 hour.

1 Potassium chloride should not be given unless renal flow is adequate; otherwise, the potassium chloride will accumulate in the body, causing hyperkalemia. Rapid infusion may cause severe pain at the infusion site and precipitate cardiac arrest. Potassium chloride must be well diluted or it will precipitate cardiac arrest. A dosage of 60 mEq per hour is too high; the IV dosage should not exceed 20 mEq of potassium chloride per hour.

Which information would the nurse teach the client in an effort to minimize the risk for chemotherapy-induced pancytopenia complications? 1 Avoid traumatic injuries and exposure to infection. 2 Perform frequent mouth care with a firm toothbrush. 3 Increase oral fluid intake to a minimum of 3 L daily. 4 Report any unusual muscle cramps or tingling sensations in the extremities.

1 Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase susceptibility to infection. Aggressive oral hygiene can precipitate bleeding from the gums. Although fluids may be increased to flush out the toxic by-products of chemotherapy, this has no effect on pancytopenia. Muscle cramps or tingling sensations in the extremities are adaptations to hypocalcemia; hypocalcemia is unrelated to pancytopenia.

Which action would be taken by the nurse when a client who is hard of hearing is scheduled for surgery? 1 Notify the operating room that the client is hard of hearing. 2 Ensure that the client has hearing aids out when being transported. 3 Allow a family member to consent for surgery on behalf of the client. 4 Request a sign language interpreter to be present immediately after surgery.

1 The operating room must be notified if a client is hard of hearing. A client can keep hearing aids in until requested by the anesthesia team to remove them. A client's hearing deficit will not diminish the ability to consent. Interpreters are generally requested as needed. There is no indication that this client will need an interpreter postoperatively.

Which question does the nurse recognize as related to the right circumstance when delegating? 1 "Is the delegation appropriate to the situation?" 2 "Is the task within the delegate's scope of practice?" 3 "Is the prospective delegate a willing and able employee?" 4 "Is the delegator able to monitor and evaluate the client appropriately?"

1 The question "Is the delegation appropriate to the situation?" is related to right circumstance. The question "Is the task within the delegate's scope of practice?" is related to right task. The question "Is the prospective delegate a willing and able employee?" is related to right person. The question "Is the delegator able to monitor and evaluate the client appropriately?" is related to right supervision.

A nurse is caring for a client with advanced-stage oral cancer who has undergone surgery. The health care provider prescribes a combination of chemotherapy and radiation therapy. What does the nurse understand to be the reason behind this treatment regimen? 1 To shrink the tumor 2 To make the client more comfortable 3 To aid healing and reduce hematomas 4 To help ensure adequate nutritional intake

2 A combination of chemotherapy and radiation therapy may be administered to a client with advanced-stage oral cancer after surgery to make the client more comfortable. Radiation therapy alone may be used before or after surgery to shrink the tumor. Clients who have undergone radical neck dissection may have drains in their incision sites that are connected to suction to aid healing and reduce hematoma development. A percutaneous endoscopic gastrostomy (PEG) tube may be inserted to permit adequate nutritional intake in clients who have difficulty swallowing.

Which statement describes a tort? 1 The application of force to the body of another by a reasonable individual 2 An illegality committed by one person against the property or person of another 3 Doing something that a reasonable person under ordinary circumstances would not do 4 An illegality committed against the public and punishable by the law through the courts

2 An individual is held legally responsible for actions committed against another individual or an individual's property. The application of force to the body of another is battery, which involves physical harm. Doing something that a reasonable person under ordinary circumstances would not do is the definition of negligence. An illegality committed against the public and punishable by the law through the courts is the definition of a crime.

Which clinical finding will most accurately indicate that the client with vomiting and diarrhea for 3 days has a fluid deficit? 1 Presence of dry skin 2 Loss of body weight 3 Decrease in blood pressure 4 Altered general appearance

2 Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb. Although dry skin may be associated with dehydration, it is also associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit.

Which right of delegation is implemented when the nurse instructs the unlicensed nursing personnel to help a high-fall-risk client with toileting every 2 hours? 1 Right task 2 Right direction 3 Right supervision 4 Right circumstance

2 Delegating the right direction or communication between the nurse and the unlicensed nursing personnel is important, especially during a shift of care. The nurse should give a clear, concise description of the task to the unlicensed nursing personnel, such as "Assist the high-fall-risk client with toileting every 2 hours," to coordinate care. The right task is delegated for a specific client within the health care professional's scope of practice. The right supervision is essential to provide appropriate monitoring, evaluation, and intervention as needed. The right circumstance considers the appropriate client setting, available resources, and other relevant factors.

A client reports severe pain 2 days after surgery. After assessing the characteristics of the pain, which initial action would the nurse take? 1 Encourage rest. 2 Obtain the vital signs. 3 Administer the prescribed analgesic. 4 Document the client's pain response.

2 Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations less than 12 breaths per minute). Pain prevents both psychological and physiologic rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.

The nurse expects to hear which lung sounds in a client who is admitted with the diagnosis of mild chronic heart failure? 1 Stridor 2 Crackles 3 Wheezes 4 Friction rubs

2 Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is heard not with chronic heart failure, but with tracheal constriction or obstruction. Wheezes are heard not with chronic heart failure, but with asthma. Friction rubs are heard not with chronic heart failure, but with pleurisy.

Which statement about sleep is correct? Select all that apply. One, some, or all responses may be correct. 1 Sleep involves three phases. 2 Sleep is associated with healing. 3 It is a state of rest that occurs for a sustained period. 4 Sleep restores a person's energy and feeling of well-being. 5 It is a cyclic physiologic process that alternates with shorter periods of wakefulness.

2, 3, 4 Sleep is associated with healing. It is a state of rest that occurs for a sustained period and restores a person's energy and feeling of well-being. Sleep involves two phases (not three), and it is a cyclic physiologic process that alternates with longer, rather than shorter, periods of wakefulness.

Which clinical indicator would a nurse expect when a client's intravenous (IV) line has infiltrated? Select all that apply. One, some, or all responses may be correct. 1 Heat 2 Pallor 3 Edema 4 Decreased flow rate 5 Increased blood pressure

2, 3, 4 The accumulation of fluid in the tissues between the surface of the skin and the blood vessels makes the skin appear pale. The accumulation of fluid in the interstitial compartment causes swelling. As the needle/catheter is dislodged from the vein, the flow rate of the IV slows or ceases. Heat is associated with phlebitis; the accumulation of room temperature IV fluid in the tissue makes the site feel cool. Increased blood pressure is a sign of circulatory overload; when an IV infusion has infiltrated, the intravascular fluid volume does not increase.

Which nursing action is inappropriate while caring for different clients after a disaster? 1 Teaching and supervising volunteers 2 Providing on-site first aid and emergency care 3 Evacuating injured and uninjured people from a danger area 4 Teaching clients about procedures that are needed for safety

3 After a disaster, evacuating the injured and uninjured people from the danger area and placing them in a safer place is done by firefighters and other disaster-trained emergency personnel. Nurses should not perform this action because they are not provided with specific rescue training. The nurse should teach and supervise volunteers to effectively perform during disasters. The nurse should provide on-site first aid treatment to the clients. The nurse should also perform the emergency care at the disaster site. Teaching the client about safety measures at home is appropriate.

Which position should the nurse place the client in to obtain an accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 Raised to 45 degrees 4 Raised to 10 degrees

3 Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30 to 45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine at 90 degrees or 10 degrees.

Which protozoa would a nurse suspect as the cause of malaria in client who has recently returned from an endemic area and is being isolated? 1 Entamoeba histolytica 2 Rickettsia 3 Plasmodium species 4 Mycoplasma

3 Plasmodium species are transmitted in endemic regions by the bite of the female Anopheles mosquito and cause malaria. Entamoeba histolytica is a type of protozoa that can cause amebic dysentery. Rickettsia is a microorganism that can cause Rocky Mountain spotted fever and typhus. Mycoplasma is a microorganism that can cause respiratory and genital tract infections.

Which discharge instructions would the nurse teach to a client who will be receiving peripheral parenteral nutrition (PPN) through a peripherally inserted central venous catheter (PICC)? 1 Learning how to change the percutaneous catheter 2 Determining which days to self-administer the PPN solution 3 Arranging for professional help to monitor the alternative nutrition 4 Scheduling administration of the PPN solution around mealtimes

3 Professional assistance will ensure correct administration, which may limit complications such as intravascular overload and sepsis; eventually, the client may self-administer the PPN with supervision. Learning how to change the percutaneous catheter usually is done by an appropriate health care provider. PPN usually is administered every day. The PPN solution usually is administered as an intermittent infusion while the client is sleeping at night, not at mealtimes; this allows for independent movement during the day.

Which need must self-help groups such as Alcoholics Anonymous (AA) meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence

3 Self-help groups are successful because they support a basic human need for belonging and acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.

A licensed practical nurse cares for a client of Italian descent after the client has given birth. What does the nurse anticipate being true of the client's preferences regarding touch? 1 The client's husband will not assist her because he cannot touch her. 2 The client might interpret a firm handshake as a sign of aggression. 3 The client would be comforted if the nurse pats her shoulder during their conversation. 4 The client would not be comfortable having her hand held casually during conversation.

3 Some cultural groups are more comfortable than others with touching or maintaining eye contact. People of Italian descent are likely to be comfortable with touching other people during conversation and with being touched. Patting the client's shoulder while talking with her might be comforting for a client of this cultural group. In Observant Judaism, a woman is in a ritual state of impurity whenever blood is coming from her uterus, such as after the birth of a child. During this time, her husband would not make physical contact with her and would not be able to assist her in moving in the bed. Many Native Americans would see a firm handshake as a sign of aggression. Because people of Italian descent are comfortable touching one other, the nurse may touch the client's hand.

Which condition does the nurse consider as the most likely cause of the client's report that their legs hurt after walking for a short time, and the pain goes away with rest but returns when walking is resumed? 1 Spinal stenosis 2 Buerger disease 3 Rheumatoid arthritis 4 Intermittent claudication

4 Intermittent claudication, a classic symptom of peripheral arterial occlusive disease, is pain caused by too little blood flow and often develops during exercise. Arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain. Spinal stenosis is associated with chronic back pain. Buerger disease is associated with foot pain and cramping; rubor may be present, and pedal pulses may be absent. Rheumatoid arthritis is associated with joint pain, erythema, and swelling; pain may be present with or without activity, particularly when one is awakening.

Which dietary modifications would the nurse include when planning nutritional education for a client with lower extremity arterial disease (LEAD)? 1 Decreasing both fluid and sodium intake 2 Increasing both calcium and potassium intake 3 Increasing both vitamin E and refined grain intake 4 Decreasing both cholesterol and saturated fat intake

4 Lower extremity arterial disease frequently is accompanied by generalized atherosclerosis; decreasing both cholesterol and saturated fat intake will help decrease lipid buildup on artery walls. Decreasing both fluid and sodium intake are inappropriate dietary modifications; this client does not have edema. Increasing both calcium and potassium is not appropriate for the client's condition because it may alter the client's electrolyte balance. Recent research indicates that supplemental vitamin E can precipitate cardiac problems and only should be taken when prescribed by a health care provider who can monitor the client's ongoing status. Increasing grain intake will add calories and may contribute to unnecessary weight gain.

Which diagnostic test may be used to distinguish vascular from nonvascular structures? 1 Chest x-ray 2 Pulmonary angiogram 3 Computed tomography 4 Magnetic resonance imaging

4 Magnetic resonance imaging is used for distinguishing vascular from nonvascular structures. An x-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. Computed tomography is performed for diagnosis of lesions difficult to assess by conventional x-ray studies.

Which nursing action would be completed after a femoral artery cardiac catheterization? 1 Provide a bed cradle. 2 Check for a pulse on the opposite leg. 3 Elevate the head of the bed. 4 Assess the groin for bleeding.

4 Most complications after cardiac catheterization involve the puncture site; included are localized hemorrhage and hematomas, as well as thrombosis of the femoral artery. Providing a bed cradle is not necessary after cardiac catheterization. Although checking for a pulse deficit is important on the affected leg, it is not the priority assessment on the unaffected leg. The client would remain supine to avoid disturbing the insertion site.

Which action would the nurse take to ensure proper body mechanics when working with another nurse to move a client with one-sided weakness up in bed? 1 Instructing the client to position one arm on each shoulder of the nurses 2 Directing the client to extend the legs and remain still during the procedure 3 Having both nurses shift their weight from the front leg to the back leg as they move the client up in bed 4 Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client

4 Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client would be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses would assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight would be shifted from the back leg to the front leg, not the front leg to the back leg; this action generates movement in the direction that the client is being moved.

Which is the briefer adaptation of the charting format for the POMR (problem-oriented medical record)? 1 SBAR 2 DARE 3 SOAPE 4 SOAPIER

4 SOAPE (subjective, objective, assessment, plan, and evaluation) is the briefer adaptation of the charting format for the POMR (problem-oriented medical record). SBAR (situation, background, assessment, and recommendation) is a method of communication among health care workers and a part of documentation. DARE (data, action, response and evaluation, and education and patient teaching) is the acronym for the four different aspects of charting using focus format. SOAPIER (subjective, objective, assessment, plan, intervention, evaluation, revision) is an acronym for seven different aspects of charting.

Which action would the hospice nurse take when a client using fentanyl transdermal patches passes away? 1 Tell the family to remove and dispose of the patch. 2 Leave the patch in place for the mortician to remove. 3 Have the family return the patch to the pharmacy for disposal. 4 Remove and dispose of the patch in an appropriate receptacle.

4 The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch and having the mortician remove the patch are inappropriate; removing the patch is not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

Which finding indicates that the therapy for vitamin B12 deficiency is having the desired effect? 1 Normal serum electrolyte levels 2 Healthy skin integrity 3 Resolution of peripheral edema 4 Improved hemoglobin (HgB) and hematocrit (Hct) levels

4 Vitamin B12 is essential for appropriate maturation of red blood cells; therefore, relieving the deficiency is expected to improve HgB and Hct levels and decrease hypoxia-related problems. This disorder is known as pernicious anemia. Normal serum electrolytes, healthy skin integrity, and resolution of peripheral edema, if present, would be secondary to improved HgB and Hct levels.

Which vitamin is an antioxidant that affects the structure of cell walls? 1 A 2 B1 3 C 4 E

4 Vitamin E is an antioxidant that hinders the oxidative breakdown of structural lipid membranes in body tissues, which is caused by free radicals in the cells. Vitamin A assists in the formation of visual purple needed for night vision. Vitamin C is used for formation of collagen, which is important for maintaining capillary strength, promoting wound healing, and resisting infection. Vitamin B1 is necessary for protein and fat metabolism and for functioning of the nervous system.

Which understanding about somatoform disorder would the nurse consider when writing the care plan? 1 It is a physiologic response to stress. 2 It is a conscious defense against anxiety. 3 It is an intentional attempt to gain attention. 4 It is an unconscious means of reducing stress.

4 When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.