MCA 1 Hesi

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Axilla Fingers Ear lobes Forehead Upper thorax

2,3 Rationale Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

The professional obligation of a nurse to assume responsibility for actions is referred to as what? Accountability Individuality Responsibility Bioethics

1 Rationale Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession; this is referred to as accountability. Individuality and responsibility are positive characteristics of the nurse but are not necessarily professional obligations. Bioethics is a field of study concerned with the ethics and philosophical implications of certain biologic and medical procedures and treatments.

While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit? Radial and apical pulse Apical and carotid pulse Radial and brachial pulse Apical and temporal pulse

1 Rationale Pulse deficit may be associated with an abnormal rhythm. Pulse deficit is the difference between the radial and apical pulse. The carotid pulse is measured when a client's condition worsens suddenly. The brachial pulse is used to measure blood pressure. The temporal pulse is used to assess the pulse in children.

A nurse is analyzing and explaining the demographics of a population under research. What phase of the nursing process is the nurse exercising? Diagnosis phase Evaluation phase Assessment phase Implementation phase

2 Rationale When the nurse is analyzing and interpreting the demographics of a study population, the nurse is exercising the evaluation phase. During the diagnosis phase, the nurse develops hypotheses related to the drug study. During the assessment phase, the nurse formulates the theoretical framework, reviews the literature, and identifies the study variables. During the implementation phase, the nurse obtains the necessary approvals, recruits subjects, and implements the study protocol. Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass.

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? Oxygen Saturation: 89% Body temperature: 101°F Blood Pressure: 130/80 mmHg Respiratory rate: 26 beats/minute

1 Rationale An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem. STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

After assessing the muscle functionality of a client, the nurse assigns a grade of F (fair) on the Lovett scale in the client. What is the muscle functionality of the client? Full range of motion with gravity Full range of motion with gravity eliminated Full range of motion against gravity with full resistance Full range of motion against gravity with some resistance

1 Rationale In the Lovett scale, grade F (fair) is given to clients who exhibit a full range of motion with gravity. Full range of motion in passive motion is assigned a P (poor) score. When a client exhibits full range of motion against gravity with full resistance, the client is given an N (normal) score. When a client exhibits full range of motion against gravity with marginal resistance, the client is given a score of G (good). Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

What does the nurse understand the term in-service education to mean? It helps achieve an organization's required competencies. It helps the nurse gain knowledge about traditional health care practices. It is a one-way education program to promote and maintain current nursing skills. It is focused on techniques and technologies that have been used successfully in the past.

1 Rationale In-service education helps achieve an organization's required competencies. Continuing education and in-service education help the nurse gain knowledge about the latest research and practice developments. Continuing education is a one-way education program to promote and maintain current nursing skills. In-service education is focused on new technologies.

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate? Relapsing Sustained Remittent Intermittent

1 Rationale Periods of febrile episodes coupled with periods of acceptable temperature values is a relapsing type of fever. These periods are often longer than 24 hours. In a sustained fever, the body temperature remains constantly above 38 oC with little fluctuations. In a remittent fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in 24 hours, the fever is termed intermittent. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

What was the goal of the Executive Order Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator? To develop a nationwide health information technology system To ensure availability of paper health records for all Americans To provide insurance coverage for all of the citizens of America To promote privacy and confidentiality of client's information

1 Rationale President George W. Bush enacted the Executive Order Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator in 2004. The objective of this order was to develop a nationwide health information technology system. It also aimed to ensure availability of electronic medical records for all Americans by 2014. The Executive Order did not aim to provide medical insurance to Americans; this was enacted by the Patient Protection and Affordable Care Act. The Health Insurance Portability and Accountability Act was enacted to promote the privacy and confidentiality of client information.

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past 2 weeks. The client states, "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client? "You are worried about paying your bills?" "Don't worry; your bills will get paid eventually." "When was the last time you were admitted for hyperglycemia?" "You really shouldn't be drinking alcohol because of your diagnosis of diabetes."

1 Rationale Reflection can help the client to elaborate. The statement "Don't worry; your bills will get paid eventually" offers false assurance; the statement "When was the last time you were admitted for hyperglycemia?" uses professional jargon; and the statement "You really shouldn't be drinking alcohol because of your diagnosis of diabetes" is offering advice, all of which can all restrict the client's response.

What should the nurse teach the parents about introducing a 6-month-old infant to solid foods? The infant should be offered one new solid food at a time. The infant may be offered fruit juices or fruit-flavored drinks. The infant should be offered solid foods after the first birthday. The infant should receive iron supplements in addition to solid foods.

1 Rationale The infant should be offered one new solid food at a time so that an allergic reaction to the new food is easily identified. The infant should not be offered fruit juices or fruit-flavored drinks because these liquids do not provide appropriate calories. The infant should be introduced to solid food after the age of six months. After the first birthday, most infants can change from breast milk or formula to whole milk. Solid foods such as cereals, fruits, vegetables, and meats provide iron and additional sources of vitamins. The infant does not need to be given iron supplements in addition to solid foods. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? Attempt to identify the client's concerns. Reassure the client that the surgery is routine. Report the client's anxiety to the healthcare provider. Provide privacy by pulling the curtain around the client.

1 Rationale The nurse should 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 healthcare 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.

What should the community nurse teach about the risk of adolescent pregnancy? Risk for premature birth Risk for having a large baby Risk for chromosomal defects Risk for increased weight gain

1 Rationale The nurse should 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 from lack of nutrition, and exposure to alcohol, drugs, and tobacco. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The nurse is assessing a client using the family health system (FHS). Which question should the nurse ask to assess the interactive process of the family? "Who are the members of your family?" "Does the family prepare and follow a budget?" "How do the family members manage their health care?" "Does any member of the family have any chronic illness?"

1 Rationale Using the FHS, the nurse can determine if the client's family is nuclear, blended, or a single-parent family when the client speaks about the different members in the family. This question helps the nurse to identify the client's relationships and determine the family's interactive processes. The nurse examines the family's coping processes by inquiring if the client adheres to a budget. The nurse examines the health processes of a family by assessing the health patterns and health management. The nurse may also identify chronic illnesses that may be stressful to the family.

A nursing student is listing the key points that need to be remembered to maintain health and wellness of the client. Which key points listed by the nursing student are accurately stated? "Internal and external variables are considered when planning care for the client." "The health belief model considers the relationship between a person's health beliefs and health behaviors." "The health promotion model highlights factors that increase individual well-being and self-actualization." "Holistic therapies are used by nurses only for pregnancy and pregnancy-related issues to help clients deal with the pain." "The American Nurses Association (ANA) emphasizes identifying a client's individual needs, prioritizing the needs, and encouraging the client's self-actualization."

1,2,3 Rationale The nurse should remember that internal and external variables are considered when planning care for the client. The nurse should know that the health belief model considers the relationship between a person's health beliefs and health behaviors. The nurse should remember that the health promotion model highlights factors that increase individual well-being and self-actualization. Holistic therapies are used by nurses either alone or in conjunction with conventional medicine. It can be used for cancer, pregnancy, and for many complicated diseases. Maslow's hierarchy of needs model emphasizes identifying a client's individual needs, prioritizing the needs, and encouraging the client's self-actualization.

A registered nurse is educating the nursing student regarding the importance of consensus building in the resolution of bioethical dilemmas. Which statements by the student nurse indicate effective learning? Multiple selection question "Consensus building is an act of discovery." "Consensus building promotes respect and agreement." "Consensus building inspires respect for unusual points of view." "Consensus building is based on choosing a particular philosophy." "Consensus building is based on the greatest good for the greatest number of people."

1,2,3 1 Rationale Consensus building is considered to be an act of discovery, as the best possible decision is reached on the basis of collective wisdom, which refer to harmonizing different points of view. When solving ethical dilemmas, consensus building focuses on promoting respect and agreement toward multiple philosophies instead of fixating on a particular moral system. Consensus building aims at bringing about an agreement among all participants in the decision-making process by encouraging respect for unusual points of view. Consensus building does not focus on a particular philosophy or moral system. Utilitarianism is based on the greatest good for the greatest number of people.

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? The nurse keeps the newborn covered in warm blankets. The nurse keeps the newborn under the radiant warmer. The nurse places the newborn on the mother's abdomen. The nurse measures the newborn's temperature regularly. The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

1,2,3 Rationale Newborns have impaired thermoregulation due to immaturity of the body systems. Therefore, the nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps to prevent heat loss. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. Placing the newborn on the mother's abdomen helps to promote warmth through skin-to-skin contact. Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help to prevent heat loss.

A victim of a car crash tells the nurse, "I don't believe in God anymore now that I'm paralyzed." The nurse asks the client to discuss how the condition has affected his or her ability to express what is important to him or her. Which aspect of spiritual assessment does this question address? Faith Vocation Connectedness Life and self-responsibility

2 Rationale In discussing how the client's condition has affected his or her ability to express what is important to him or her, the nurse is addressing the vocation aspect of the client's spirituality. Questions about prayer, religious practices, and the meaning of life address the faith aspect of spirituality. Questions about community and feeling associated with spiritual practices address the connectedness aspect of spirituality. Questions about how the paralysis affects the client's next steps and changes in the client's life address the life and self-responsibility aspect of spirituality. Test-Taking Tip: Do not read information into questions, and avoid speculating. Reading into questions creates errors in judgment.

Which client is likely to have a health promotion nursing diagnosis? The client with acute pain due to appendicitis. The client who is willing to take a 30-minute walk daily. The elderly client with dementia admitted to the healthcare facility. The client with reduced cognitive ability while recovering from surgery.

2 Rationale A health promotion nursing diagnosis is a clinical judgment of an individual's desire to increase well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes the client's response to a particular health condition. A risk nursing diagnosis describes an individual's response to health conditions that may develop in a vulnerable individual. The elderly client with dementia may have a risk nursing diagnosis for confusion. The client recovering from surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls

What is the role of a nurse administrator in a healthcare setting? Providing surgical anesthesia under the guidance and supervision of an anesthesiologist Preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development Providing comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions Providing knowledge about current nursing practices, trends, theories, and necessary skills in laboratories and clinical settings

2 Rationale A nurse administrator's function is to prepare the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development. A certified registered nurse anesthetist provides surgical anesthesia under the guidance and supervision of an anesthesiologist. The nurse practitioner provides comprehensive care and directly manages the medical care of clients who are healthy or have chronic conditions. Nurse educators provide knowledge about current nursing practices, trends, theories, and necessary skills in laboratories and clinical settings. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs? Level 1 Level 2 Level 3 Level 4

2 Rationale A nurse who assists an older client in getting to the washroom is fulfilling the safety and security need, which is the second level of need according to Maslow's hierarchy of needs. The first level involves physiological needs such as air, water, and food. Belonging needs such as friendship, social relationships, and sexual love fall under the third level of need. The fourth level of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth and achievement. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

According to Erikson's theory of psychosocial development, which opposing conflicts is an older adult likely to face? Trust versus Mistrust Integrity versus Despair Intimacy versus Isolation Industry versus Inferiority

2 Rationale According to Erikson's theory of psychosocial development, an older adult is likely to face the opposing conflict of Integrity versus Despair. An infant in the age group between birth and one year old is likely to face the opposing conflicts Trust versus Mistrust. A young adult is likely to face the opposing conflicts Intimacy versus Isolation. School-aged children between the ages of 6 and 11 years are likely to face the opposing conflicts Industry versus Inferiority.

A nurse is using evidence-based practice to formulate a treatment plan for a client. The nurse uses the PICOT format to ask a clinical question. What should be the next step in the decision-making process? Critically appraising all the evidence available Gathering the most relevant and best evidence Sharing the outcomes of the evidence-based practice changes with others Integrating all available evidence with clinical expertise and client preferences

2 Rationale After asking the clinical question, the nurse should gather the most relevant and best evidence. The nurse may perform a critical appraisal after gathering all the necessary evidence. Sharing the outcomes of the evidence-based practice changes with others is the last step of the decision-making process. After gathering relevant evidence and appraising the same, the nurse should integrate it with clinical expertise and client preferences. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

A client requests information about the prescribed medication regimen. What is the best response by the nurse? Give a computer printout about the medication to the client. Ask the client to state what is already known about the medication. Advise talking to the primary healthcare provider to seek information about the medication. Delegate the task of sharing information about the medication to the licensed practical nurse.

2 Rationale Assessing the client's knowledge to delineate baseline information should be done before planning appropriate health teaching. Providing written material without knowing the client's ability to read is inappropriate; also, it limits the nurse's personal involvement in the teaching process. Having the client talk with the healthcare provider avoids carrying out the nurse's responsibility to provide teaching about a prescribed medication regimen. Health teaching about medication is the responsibility of the registered professional nurse.

Which is an indirect nursing care intervention? Administering medications Managing the client's environment Counseling the family during a time of grief Inserting intravenous infusion

2 Rationale Indirect nursing care interventions are treatment actions not performed directly to the client but are done to aid the client. Indirect care intervention includes managing the client's environment. Direct care interventions include administration of medications, counseling the family during a time of grief, and insertion of an intravenous infusion.

A nurse who promotes freedom of choice for clients in decision-making best supports which principle? Justice Autonomy Beneficence Paternalism

2 Rationale The principle of autonomy relates to the freedom of a person to form his or her own judgments and actions. The nurse promotes autonomy nonjudgmentally so as not to infringe on the decisions or actions of others. Justice means to be righteous, equitable, and to act or treat fairly. Beneficence relates to the state or act of doing good and being kind and charitable. It also includes promotion of well-being and abstaining from injuring others. Paternalism encompasses the practice of governing people in a fatherly manner, especially by providing for their needs without infringing on their rights or responsibilities. STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend 7 hours sleeping and 3 hours studying than to cut sleep to 6 hours and study 4 hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency.

What are the four core roles for the advanced practice registered nurse (RN)? Ostomy care nurse Clinical nurse specialist Certified nurse midwife Certified RN anesthetist Certified diabetes educator Certified nurse practitioner

2,3,4,6 Rationale Clinical nurse specialist (CNS), certified nurse midwife (CNM), certified RN anesthetist (CRNA) and certified nurse practitioner (CNP) are the four core roles for the advanced practice registered nurse (APRN). Ostomy care nurse and certified diabetes educator (CDE) are not core roles for advanced practice registered nurses (APRNs). They are specialized nurse educators.

While assessing a client, a nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? Client has lordosis. Client is an older adult. Client has osteoporosis. Client has a history of smoking. Client has chronic lung disease.

2,4,5 Rationale The 1:1 ratio of the anteroposterior diameter and transverse diameter of the chest indicates a barrel-shaped chest. This is a characteristic feature in an older adult who smokes and has chronic lung disease. In lordosis, there is an increase in lumbar curvature. Osteoporosis is a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client? Touch Reminiscence Reality orientation Validation therapy

3 Rationale 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 to induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps to bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help a client in a confused state.

The nurse is caring for a patient who was just diagnosed with diabetes mellitus. The patient appears willing to learn how to manage the disease by stating, "I will take insulin (Humulin R) regularly to maintain my blood sugar levels." What should the nurse infer from this information? The patient is not motivated. The patient is intrinsically motivated. The patient is extrinsically motivated with self-determination. The patient is extrinsically motivated without self-determination.

3 Rationale If the patient is extrinsically motivated with self-determination to manage their illness, then the patient shows interest in learning new tasks that would benefit their health. If the patient is not motivated, then they may not participate in any activities. If the patient is intrinsically motivated, then they may approach health care professionals without external motivation. If the patient participates in activities because of the pressure of family members and does not know the importance of the activity, then the patient is said to be extrinsically motivated without self- determination.

What is the significance of the procedure depicted in the figure? Evaluating heart rate Evaluating popliteal occlusion Evaluating arterial insufficiency Evaluating the blood pressure

3 Rationale In the given figure, the nurse is assessing the ulnar pulse of the client. This procedure helps to evaluate arterial insufficiency to the hand. The radial pulse is used to assess the heart rate. The popliteal artery, which is present behind the knee, may be assessed to evaluate popliteal aneurysms and peripheral vascular disease. The brachial pulse is used to note the blood pressure.

An octogenarian client tells the nurse, "Please do not give me dietary instructions post-surgery. I've had several surgeries in my lifetime and I know what to eat." Which variable influences the client's health beliefs and practices? Emotional factors Socioeconomic factors Intellectual background Perception of functioning

3 Rationale In the given situation, the client has acquired knowledge from past experiences. This shows the influence of the client's intellectual background on his or her health beliefs and practices. The manner in which a client handles his or her emotions when confronted with illnesses also influences health beliefs and practices. Social and economic variables also influence the client's health beliefs and practices. The way in which a client perceives physical functioning, also influences a client's health beliefs and practices. These factors are not influencing the client's decision in this case Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? Headache Pallor Paresthesias Blurred vision

3 Rationale Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention? Substitute a supplemental drink for the meal. Spoon-feed the client until the food is completely eaten. Allow the client a longer period of time to complete the meal. Arrange a consultation for the placement of a gastrostomy tube.

3 Rationale Older clients may display psychomotor retardation and need more time to complete the tasks associated with the activities of daily living; mealtimes should be relaxing and social. Supplemental drinks should augment meals and be offered between meals, not as a substitute for meals. Clients should be encouraged to feed themselves to remain as independent as possible; spoon-feeding may not mirror the pace of eating preferred by the client, and forcing the client to eat all of the food may precipitate anxiety, frustration, and agitation. Placement of a gastrostomy tube is premature.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? Justice Veracity Autonomy Beneficence

3 Rationale The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.

A client has a right-above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best response? "Tell me what you think happened." "You will remember more as you get better." "You were in a work-related accident this morning." "It was necessary to amputate your leg after the accident."

3 Rationale The correct response is truthful and provides basic information that may prompt recollection of what occurred; it is a starting point. Asking the client to tell the nurse what happened ignores the client's question; avoidance may increase anxiety. Saying "you will remember more as you get better" ignores the client's question; the frustration of trying to remember will increase anxiety. Saying "it was necessary to amputate your leg after the accident" is too blunt for the initial response to the client's question; the client may not be ready to hear this at this time.

A client who has sustained an accident says, "I have a dream of conquering the world's highest mountain range." To which level of need does the given scenario refer to, according to Maslow's hierarchy of needs? The given scenario relates to the first level that includes physiological needs. The given scenario relates to the fourth level that includes self-esteem needs. The given scenario relates to the final level that includes self-actualization needs. The given scenario relates to the second level that includes safety and security needs. scenario relates to the final level that includes self-actualization needs. The given scenario relates to the second level that includes safety and security needs.

3 Rationale The given scenario relates to the final level of Maslow's hierarchy of needs: the self-actualization needs. The self-actualization need refers to self-fulfillment. Physiological needs refer to the need for clean air, water, and food. Self-esteem needs refer to self-confidence, usefulness, achievement, and self-worth. Safety and security needs refer to physical and psychological security. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care? Meet the clients' family. Read the clients' medical reports. Participate in the bedside rounds. Visit the clients and introduce self.

3 Rationale The nurse should participate in bedside rounds with the healthcare team from the previous shift. The nurse who is completing care for one shift prepares the change-of-shift report to communicate client details to the nurse in the next shift. These bedside rounds provide patient-centered care as the nurse shares information about the client's condition, status of problems, and treatment plan for the next shift. The nurse can meet the client's family after obtaining firsthand information from the nurse completing the shift. The nurses review the client's medical reports and discuss treatment plans for the next shift after completing the bedside rounds. The nurse may meet the client during bedside rounds or after obtaining the handover report. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

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

3 Rationale 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.

Which organization assists in establishing policies related to Medicare and Medicaid payment for meaningful use of EHRs? National Institute of Health (NIH) American Medical Informatics Association (AMIA) Center for Medicare and Medicaid Services (CMS) Health Information Management Systems Society (HIMSS)

3 Rationale CMS rules specify how health care facilities and providers make meaningful use of the EHRs and technologies to receive payment from Medicare and Medicaid. The National Institutes of Health uses translational bioinformatics for medical research. The American Medical Informatics Association and the Health Informatics Management Systems Society have been involved in identifying nursing informatics competencies.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? Stage I Stage II Stage III Unstageable

4 Rationale A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? Alkalosis Renal failure Hypervolemia Pulmonary edema

4 Rationale Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater. Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence.

A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error? Labeling Collecting Clustering Interpreting

4 Rationale An inaccurate match between clinical cues and the nursing diagnosis is an interpreting error. Interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors. A labeling error is a failure to validate data. Collecting errors include inaccurate data, missing data, or disorganization. Errors at the clustering level include an insufficient cluster of cues, premature or early closure, or incorrect clustering.

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? Get a full report from the first nurse and adjust the plan accordingly. Ask the primary healthcare provider for a report on the client's condition and plan appropriately. Tell the client about the change in staff responsibilities and assess the client's reaction. Assess the client's present status and include the client in a discussion of revisions to the plan of care.

4 Rationale Because the client is feeling a loss of control, it is most important to include the client in revision of the plan of care. Getting a full report from the first nurse does not consider changes in the client or obtain the client's input. Planning nursing care is within the nurse's function and judgment, not the primary healthcare provider's; also, the client should be included. Telling the client of the change in staff responsibilities is an authoritarian approach and does not include the client in planning future care. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A nurse is evaluating different situations related to obtaining informed consent. Which situation does the nurse consider to be the most appropriate method of obtaining informed consent? A client consents to a medical procedure after the nurse has explained its risks and benefits in detail. A client provides consent for a surgery after the primary healthcare provider gives the details of the benefits of the surgery. A client consents to a medical procedure after all the details of the procedure have been provided using strictly medical terminology. A client provides consent after the primary healthcare provider has given a detailed explanation of the risks, benefits, and alternatives to the procedure.

4 Rationale Proper informed consent can be obtained after the primary healthcare provider gives a detailed explanation about the risks and benefits of treatment and all available alternatives to the procedure. Because the nurse does not perform surgeries or direct medical procedures, the nurse cannot explain the procedure to obtain proper informed consent. Proper informed consent cannot be obtained from the client unless the risks and alternatives of the medical procedures have been explained along with the benefits by the primary healthcare provider. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client? Abnormal rapid heart rate Abnormal rapid breathing Increased body temperature Increased expired carbon dioxide

4 Rationale The first sign of malignant hyperthermia[1][2] is increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.

A nurse is hired to work in a facility where the nurse assumes responsibility for a number of clients' needs. What is this nursing care delivery system called? Team nursing Modular nursing Functional nursing Primary care nursing

4 Rationale This is the definition of primary care nursing. In team nursing there is a mix of staff members who provide care along with a team leader who usually is a registered nurse. In modular nursing clients are assigned according to geographic location and a variety of professionals are involved; this is similar to team nursing, but the teams are smaller. In functional nursing the nurse manager makes work assignments with specific tasks for each nurse.

A registered nurse is teaching a nursing student about skin assessment. Which statement made by the nursing student indicates the need for further teaching? "Skin assessments are best performed in daylight." "Skin assessments performed at cool room temperatures can result in cyanosis." "Skin assessment performed at warm room temperatures can result in vasodilatation." "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light."

4 Rationale Though skin assessments are best conducted in daylight, in the absence of sunlight, they are best performed in fluorescent lighting. Skin exposure during skin assessments in cool room temperature can result in cyanosis. Skin exposure during skin assessments made in warm room temperature can result in vasodilatation.

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? Time available for care Validity of the problem Method for providing care Effectiveness of the interventions

4 Rationale 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.

What are the signs and symptoms observed in the human body with a decrease in body temperature? Shivering Profuse sweating Flushed appearance Dilation of blood vessels Contraction of blood vessels

1,5 Rationale A client who has decreased body temperature may experience shivering due to contraction of the blood vessels in the body. The client who has decreased body temperature may not experience profuse sweating, flushed appearance, and dilated blood vessels. These signs and symptoms appear with an increase in body temperature.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? Justice Veracity Autonomy Beneficence

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Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? Primary nurse Nurse clinician Nurse coordinator Clinical nurse specialist

1 Rationale 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 healthcare 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 a nurse specially prepared for one very specific clinical role. It requires a master's degree level of education. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options . Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.

What are common negligent acts of nurses found in the hospital setting? Failure to notify the healthcare provider of problems Failure to follow the six rights of medication administration Failure to ensure the safety of a client with disequilibrium problems Failure to notify a family member about the client's current status Failure to administer medication during an emergency without consulting with the nursing manager

1, 2, 3 Rationale Common negligent acts of nurses include failure to notify the healthcare provider of problems, failure to follow the six rights of medication administration, and failure to ensure the safety of a client with disequilibrium problems. Failure to notify the family member about the client's current status is not a common negligent act. The nurse does not have the authority to administer medications without a primary healthcare provider's order. Therefore, this action is also not a common negligent act.

Which warning signals should the nurse observe in a child suspected to be a victim of abuse? The child doesn't want to be touched by anyone. The child sleeps for an average of 15 hours a day. The child frequently visits the emergency department. The child suffers from fever and tenderness in the abdomen. The child looks at the caregiver before answering any question.

1.3.5 Rationale The child may become scared if touched. The physical abuse may cause injuries and the child may visit the emergency department frequently. An abused child may look at the caregiver before answering any question due to fear. The child sleeping for an average of 15 hours a day does not indicate abuse. Fever and tenderness in the abdomen are not signs of abuse; it could indicate an organic cause.

A client says, "None of the medications will work on me because I am away from my holy land." What course of action should the nurse take to comply with teamwork and collaboration competency according to the Quality and Safety Education for Nurses (QSEN)? Provide care to the client with respect to his or her diversity, values and beliefs Approach the agency chaplain to discuss the spiritual needs of the client Conduct thorough research on the effect of emotional distress on the client's health Use the flow chart data to provide the best care and monitor the outcome of care processes

2 Rationale According to Quality and Safety Education for Nurses (QSEN) competency, the nurse complies with teamwork and collaboration competency to function effectively within the nursing and interprofessional teams. In the given scenario, the nurse should collaborate with the agency chaplain to discuss the client's spiritual needs. The nurse complies with the patient-centered care competency by providing care to the client with respect to his or her diversity, values, and beliefs. The nurse complies with the evidence-based practice competency by conducting thorough research on the effect of emotional distress on the client's health. The nurse complies with the quality improvement competency by using the flow chart data to provide the best possible care and monitor the outcome of care processes.

When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? Skin breakdown Aspiration pneumonia Retention ileus Profuse diarrhea

2 Rationale Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.

A registered nurse is teaching a student nurse about quality improvement processes to improve client outcomes and efficiency of health systems. Which statement of the student nurse indicates effective learning? "Quality improvement processes receive funding from external sources such as grants." "Quality improvement processes sometimes require institutional review board (IRB) approval." "Quality improvement processes measure the effects of practice on a specific client population." "Quality improvement processes store data from client records or clients who are in a specific area." "Quality improvement processes focus on the implementation of already known evidence into practice."

2,3,4 Rationale Quality improvement sometimes needs IRB approval. It measures the effects of practice and practice change on a specific client population. It stores data from client records or clients who are in a specific area, such as on a client care unit or admittance information to a particular hospital. It receives funding from an internal source such as a health care agency. It is not associated with the implementation of evidence that is already known into practice.

A registered nurse is teaching a nursing student about the characteristics of various healthcare plans. Which statements about preferred provider organizations (PPOs) by the nursing student need correction? Preferred provider organizations are focused on health maintenance. Preferred provider organizations reimburse nursing home payments. Preferred provider organizations cover children who are not poor enough for Medicaid. Preferred provider organizations have deductibles that clients must meet before the insurance pays. In a preferred provider organization, a contractual agreement exists between a set of providers and one or more purchasers.

2,3,4 Rationale The Medicare healthcare plan reimburses nursing home funding. The State Children's Health Insurance Program (SCHIP) covers children who are not poor enough for Medicaid. Private insurance may have deductibles that clients must meet before the insurance pays. A preferred provider organization is focused on health maintenance. Preferred provider organizations involve a contractual agreement between a set of providers and one or more purchasers.

A nurse is caring for a client with pain after surgery. The nurse takes the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. Which standard of practice does the nurse perform? Planning Diagnosis Assessment Implementation

3 Rationale When a nurse collects comprehensive data relevant to the client's health or the situation, it is considered assessment. In the given scenario, the nurse is assessing the client to minimize pain. Planning refers to instances when a nurse develops a plan to attain expected outcomes. Diagnosis refers to instances when the nurse analyzes the assessment data to determine the diagnoses or issues. Implementation refers to instances when the nurse implements the identified plan. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

How does a nurse prepare a "factual" record when performing a client documentation? By providing a logical order for the communication By using exact measurements for each activity of the client By providing complete and appropriate information in each client record By recording descriptive and objective information of what the nurse sees, hears, feels, and smells

4 Rationale A factual record contains descriptive and objective information about what a nurse sees, hears, feels, and smells. An organized record communicates the information in a logical order. The use of exact measurements establishes accuracy. The nurse prepares a complete record by providing a complete and appropriate record that includes all essential information.

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? It stimulates plasma cells directly. A delayed titer of antibodies is generated. It provides immediate active immunity. A passive immunity is produced.

4 Rationale Tetanus antitoxin stimulates the body to create protective antibodies to the tetanus toxin. It helps provide these antibodies, which confer immediate passive immunity that lasts about 7-14 days. Passive immunization is the administration of immunoglobulin prepared from individuals known to have high levels of antibodies to the infectious agent in question. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity.

A nurse performs lung assessments of four clients. The details are given below. Which client has inflamed pleura? Client A Client B Client C Client D

D Rationale The breathing sounds in a pleural rub or an inflamed pleura are of a dry or grating quality that is heard in the lower portion of the anterior lateral lung, as observed in client D. High-pitched, continuous musical sounds heard all over the lung are wheezing breath sounds heard when there is a high-velocity airflow through severely narrowed or an obstructed airway. Loud, low-pitched, rumbling coarse sounds heard in the trachea and bronchi are rhonchi, which are observed during muscular spasm or when fluid or mucus is present the in larger airways. Fine crackles, medium crackles, and coarse crackles heard in client C are heard in lung bases due to random and sudden reinflation of groups of alveoli, which causes a disruptive passage of air through the small airways. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. In this question, you are expected to know the breath sounds associated with inflamed pleura and the site of auscultation. At least knowing one of the two components will help you arrive at the answer. These questions usually reflect the analyzing level of cognitive thinking.

A client who has liver failure says, "I have complete trust in God and I am sure he will take care of my family even if I am not here." Which concept does this most exemplify? Faith Religion Connectedness Transcendence

1 Rationale The client's trust that God will take care of his or her family exemplifies faith. An example of religion would be if the client carried out specific rituals or practices to cope. Connectedness involves finding comfort through one's relationship with oneself, other people, and or with a higher power. Transcendence is the belief in a greater force outside of the material world.

Which tasks should a nurse perform in order to comply with public health laws? Report cases of communicable diseases Report incidences of domestic violence Provide emergency assistance at an accident scene Notify the primary healthcare provider of any client-related problems Ensure that clients in a community have received necessary immunizations

1,2,5 Rationale To comply with public health laws, the nurse is required to report cases of communicable diseases. The nurse must also report cases of suspected domestic violence, child abuse, or elder abuse. The nurse should ensure that clients in a community have received all necessary immunizations. To comply with Good Samaritan laws, the nurse should provide emergency assistance consistent with his or her level of expertise at an accident scene. Notifying the primary healthcare provider of client-related problems is not an example of complying with public health laws.

When might a nurse be charged with client abandonment? If a nurse refuses to accept an assignment If a nurse walks out when staffing is inadequate If a client suffers an injury due to the nurse's inattention If a nurse makes a written protest to the nursing administrators

2 Rationale The nurse should never walk out when staffing is inadequate because this action may result in client abandonment. If a nurse refuses to accept an assignment, then he or she is considered insubordinate. If a client suffers an injury due to inattention and the nurse had already brought this to the attention of the nursing supervisor, then the caregiver was attempting to act reasonably. If a nurse has to accept unreasonable assignments, he or she needs to make written protests to nursing administrators.

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve? Aortic Mitral Pulmonic Tricuspid

3 Rationale The second left intercostal space (ICS) along the sternal border reflects sounds from the pulmonic valve. The correct landmark for auscultating the aortic valve is at the right second ICS at the sternal border; for the mitral valve (apical pulse) at the left fifth ICS in the midclavicular line; and for the tricuspid valve at the left fifth ICS at the sternal border.

A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse? Nurse practitioner Nurse administrator Certified nurse-midwife Clinical nurse specialist

4 Rationale The hospital will most likely hire a clinical nurse specialist. A clinical nurse specialist is an expert in a specific area of practice and in a particular setting such as an intensive care unit. A nurse practitioner has expertise in taking care of clients in an outpatient, ambulatory care, or community care setting. A nurse administrator looks after the management of the care provided to clients within a health-care agency. A certified nurse-midwife provides care to women during their pregnancy, labor or delivery. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.