N-Ten Final

A nurse on a medical-surgical unit has received a change-of-shift report and will care for four clients. Which of the following tasks should the nurse assigned to an assistive personnel (AP)? A. updating the plan of care for a client who's postoperative B. Reinforcing teaching with the client who is learning to walk using a quad cane. C. Reapplying a condom catheter for a client who has urinary incontinence. D. Applying a sterile dressing to a pressure injury.

C. The application of a condom catheter is a noninvasive routine procedure that can be delegated to an AP.

Middle adults tend to gain weight. What is a reason for the middle adult to gain weight?

slower basal metabolic rate (BMR) and reduced physical activity

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist

A. The provider must be knowledgeable about any medication prescribed for the client including its actions, effects, and interactions. C. A pharmacist must be knowledgeable about any medication dispensed for the client including its actions, affects, and interactions. D. A registered nurse must be knowledgeable about any medication administered including its actions, effects, and interactions

A college student 20 years of age is preparing for a career as a teacher. What need initially influences the decision to establish a career?

Becoming independent of one's family

A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assigned to a PN? A. Creating a plan of care for a client who is recovering following a stroke. B. Assessing a pressure injury on a client who is on bedrest. C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a meter- dosed in-haler

C. Providing nasopharyngeal suctioning is within the scope of practice of the PN.

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit.

C. The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. Protect and move clients in close proximity to the fire.

A facility is planning to implement an update to the electronic health record. This update is designed to facilitate documentation of critical changes in clients' condition to save time that nurses spend when documenting these changes. An informatics nurse specialist asks a group of staff nurses to test this update to determine if it is working as it was designed. The nurses are involved in which type of testing?

User acceptance

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawback?

Vulnerability to legal liability since nurse's safe, routine care is not recorded

A nurse cares for patients in a chiropractic office. What patient education might this nurse perform? Select all that apply. A.Applying heat or ice to an extremity B.Explaining the use of electrical stimulation C.Teaching a patient relaxation techniques D.Teaching a patient about a prescription E.Explaining an invasive procedure to a patient F.Teaching about dietary supplements

a, b, c, f. Chiropractors may combine the use of spinal adjustments and other manual therapies with several other treatments and approaches including heat and ice, electrical stimulation, relaxation techniques, rehabilitative and general exercise, counseling about weight and diet, and using dietary supplements. Chiropractors do not prescribe medication or perform invasive procedures.

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A. A patient who has uncontrolled hypothyroidism. B. A patient with coronary artery disease. C. A patient who has GERD. D. A patient who is HIV positive. E. A patient who is taking corticosteroids for arthritis. F. A patient with a urinary tract infection.

a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

Which patients would a nurse assess for menstrual cycle irregularities? Select all that apply. A. A patient who is breast-feeding B. A patient who is diagnosed with anorexia C. A patient who chooses to abstain from sexual intercourse D. A patient who has pelvic inflammatory disease E. A patient who is obsessed with exercising F. A patient who has a spinal cord injury

a, b, d, e. Causes of menstrual cycle irregularities include pregnancy or breast-feeding, eating disorders, extreme weight loss, excessive exercising, and pelvic inflammatory disease, as well as many other causes. Abstaining from sex and spinal cord injuries are not causes of menstrual irregularities.

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. A.Arrange for assessment for depression and treatment. B.Discourage napping during the day. C.Decrease fluids during the evening. D.Administer diuretics in the morning. E.Encourage patient to engage in some type of physical activity. F.Assess medication for side effects of sleep pattern disturbances.

a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.

A nurse is teaching parents about normal developmental aspects of sexuality in their children. Which statements from parents would warrant further teaching? Select all that apply. A. "When my 2-year-old son touches his genitals, I push his hand away and tell him 'No'." B."I should wean my infant by 4 months and encourage him to use a sippy cup." C."I should explain sexuality to my 9-year-old in a factual manner when she asks me questions about her body." D."I should explain about body changes to my 11-year-old prior to them happening to alleviate her fears." E."I should teach my 10-year-old about contraception and ways to avoid sexually transmitted diseases." F."I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs."

a, b, e, f. Self-manipulation of genitals is normal behavior; parents should avoid telling a child this as "bad." Parents should avoid early weaning of infants to prevent oral deprivation. Parents should explain contraception and STIs to their adolescent children; it would be premature to do so for a 10-year-old. Parents should share their beliefs and moral system with their children. Parents should also give their children the desired information about sexuality in a clear, factual form and give them information about body changes before they experience them, to alleviate fears.

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. A.Daily mental activities B.Daily physical activities C.Morning and evening body temperature D.Daily measurement of fluid intake and output E.Presence of anxiety or worries affecting sleep F.Morning and evening blood pressure readings

a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.

A nurse mentor is teaching a new nurse about the underlying beliefs of CHAs versus allopathic therapies. Which statements by the new nurse indicate that teaching was effective? Select all that apply. A."CHA proponents believe the mind, body, and spirit are integrated and together influence health and illness." B."CHA proponents believe that health is a balance of body systems: mental, social, and spiritual, as well as physical." C."Allopathy proponents believe that the main cause of illness is an imbalance or disharmony in the body systems." D."Curing according to CHA proponents seeks to destroy the invading organism or repair the affected part." E."The emphasis is on disease for allopathic proponents and drugs, surgery, and radiation are key tools for curing." F."According to CHA proponents, health is the absence of disease."

a, b, e. With CHA, mind, body, and spirit are integrated and together influence health and illness, and illness is a manifestation of imbalance or disharmony. Allopathic beliefs include: The main causes of illness are considered to be pathogens (bacteria or viruses) or biochemical imbalances, curing seeks to destroy the invading organism or repair the affected part, and emphasis is on disease and high technology. Drugs, surgery, and radiation are among the key tools for dealing with medical problems. According to allopathic beliefs, health is the absence of disease.

A discharge nurse is evaluating patients and their families to determine the need for a formal discharge plan or referrals to another facility. Which patients would most likely be a candidate for these services? Select all that apply. A. An older adult who is diagnosed with dementia in the hospital B. A 45-year-old man who is diagnosed with Parkinson's disease C. A 35-year-old woman who is receiving chemotherapy for breast cancer D. A 16-year-old boy who is being discharged with a cast on his leg E. A new mother who delivered a healthy infant via a cesarean birth F. A 59-year-old man who is diagnosed with end-stage bladder cancer

a, b, f. The patients who are most likely to need a formal discharge plan or referral to another facility are those who are emotionally or mentally unstable (e.g., those with dementia), those who have recently diagnosed chronic disease (e.g., Parkinson's disease), and those who have a terminal illness (e.g., end-stage cancer). Other candidates include patients who do not understand the treatment plan, are socially isolated, have had major surgery or illness, need a complex home care regimen, or lack financial services or referral sources.

A nurse decides to become a home health care nurse. Which personal qualities are key to being successful as a community-based nurse? Select all that apply. A. Making accurate assessments B. Researching new treatments for chronic diseases C. Communicating effectively D. Delegating tasks appropriately E. Performing clinical skills effectively F. Making independent decisions

a, c, e, f. Nurses working in the community must have the knowledge and skills to make accurate assessments, work independently, communicate effectively, and perform clinical skills accurately. Community-based nurses may be researchers and occasionally delegate care, but these are not key qualities for this type of nursing.

A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply. A. Advocacy is the protection and support of another's rights. B. Patient advocacy is primarily performed by nurses. C. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities. D. Nurse advocates make good health care decisions for patients and residents. E. Nurse advocates do whatever patients and residents want. F. Effective advocacy may entail becoming politically active.

a, c, f. Advocacy is the protection and support of another's rights. Among the patients with special advocacy needs are the very young and the older adult, those who are seriously ill, and those with disabilities; this is not a comprehensive list. Effective advocacy may entail becoming politically active. Patient advocacy is the responsibility of every member of the professional caregiving team—not just nurses. Nurse advocates do not make health care decisions for their patients and residents. Instead, they facilitate patient decision making. Advocacy does not entail supporting patients in all their preferences.

A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. A. Stop performing the exercises. B. Decrease the number of repetitions performed. C. Reevaluate the nursing care plan. D. Move to the patient's other side to perform exercises. E. Encourage the patient to finish the exercises and then rest. F. Assess the patient for other symptoms.

a, c, f. When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

A nurse who is newly hired to manage a busy pediatric office is encouraged to use a transactional leadership style when dealing with subordinates. Which activities best exemplify the use of this type of leadership? Select all that apply. A. The manager institutes a reward program for employees who meet goals and work deadlines. B. The manager encourages the other nurses to participate in health care reform by joining nursing organizations. C. The manager promotes compliance by reminding subordinates that they have a good salary and working conditions. D. The manager makes sure all the employees are kept abreast of new developments in pediatric nursing. E. The manager works with subordinates to accomplish all the nursing tasks and goals for the day. F. The manager allows the other nurses to set their own schedules and perform nursing care as they see fit.

a, c. Instituting a reward program and reminding workers that they have a good salary and working conditions are examples of transactional leadership, which is based on a task-and-reward orientation. Team members agree to a satisfactory salary and working conditions in exchange for commitment and compliance to their leader. Encouraging nurses to participate in health care reform is an example of a transformational leadership style. Ensuring that employees keep abreast of new developments in nursing care is a characteristic of quantum leadership. The group and leader work together to accomplish mutually set goals and outcomes with the democratic leadership style, and the laissez-faire style encourages independent activity by group members, such as setting their own schedules and work activities.

A nurse is performing sexual assessments of male patients in a long-term care facility. Which patients would the nurse flag as having an increased risk for erectile dysfunction? Select all that apply. A. A 72-year-old man with a history of diabetes B. A 78-year-old man who has a new partner C. A 75-year-old man who has Parkinson's disease D. An 80-year-old man who is an alcoholic E. An 85-year-old man who takes antihypertensive medication F. A 76-year-old man who smokes tobacco

a, d, e. Risk factors for erectile dysfunction include history of diabetes, spinal cord trauma, cardiovascular disease, surgical procedure, alcoholism, and use of antihypertensives, antidepressants, or illicit drugs. Having a new partner may be a risk factor for premature ejaculation, and a history of Parkinson's disease may predispose the patient to delayed ejaculation. Smoking is not a risk factor for impotence.

A nurse is a servant leader working in an economically depressed community to set up a free mobile health clinic for the residents. Which actions by the leader BEST exemplify a key practice of servant leaders? Select all that apply A. The nurse motivates coworkers to solicit funding to set up the clinic. B. The nurse sets only realistic goals that are present oriented and easily achieved. C. The nurse forms an autocratic governing body to keep the project on track. D. The nurse spends time with supporters to help them grow in their roles. E. The nurse first ensures that other's lowest priority needs are served. F. The nurse prizes leadership because of the need to serve others.

a, d, f. In order to serve as servant leaders, nurses need to invest in those who support the organization's values, show passion, can play to their strengths, and demonstrate a positive attitude. They should develop their vision to see the future related to a current anticipated need, and motivate others to follow and engage. They also need to provide ongoing opportunities for collaborations, sharing, reflection, encouragement, and celebration, as well as hard work. The servant leader allows others to have a voice, to exercise control, and to practice leading themselves. The servant first makes sure that other people's highest priority needs are being served. The best test, and most difficult to administer, is: Do those served grow as people? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?

Newly hired nurses in a busy suburban hospital are required to read the state nurse practice act as part of their training. Which topics are covered by this act? Select all that apply. A. Violations that may result in disciplinary action B. Clinical procedures C. Medication administration D. Scope of practice E. Delegation policies F. Medicare reimbursement

a, d. Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act. Nurse practice acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through federal legislation.

A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. A.Instruct the patient to avoid sudden position changes that may cause dizziness. B.Recommend that the patient restrict fluid until after exercising is finished. C.Instruct the patient to push a little further beyond fatigue each session. D.Instruct the patient to avoid exercising in very cold or very hot temperatures. E.Encourage the patient to modify exercise if weak or ill. F.Recommend that the patient consume a high-carb, low-protein diet.

a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

A nurse is caring for a patient who has crippling rheumatoid arthritis. Which nursing intervention best represents the use of integrative care? A.The nurse administers naproxen and uses guided imagery to take the patient's mind off the pain. B.The nurse prepares the patient's health care provider-approved herbal tea and uses meditation to relax the patient prior to bed. C.The nurse administers naproxen and performs prescribed range-of-motion exercises. D.The nurse arranges for acupuncture for the patient and designs a menu high in omega-3 fatty acids.

a. Adding guided imagery (CHA) to the administration of pain medications (allopathy) is an example of integrative care. A person who uses integrative care uses some combination of allopathic medicine and CHA.

A nurse is using time management techniques when planning activities for patients. Which nursing action reflects effective time management? A. The nurse asks patients to prioritize what they want to accomplish each day B. The nurse includes a "nice to do" for every "need to do" task on the list C. The nurse "front loads" the schedule with "must do" priorities D. The nurse avoids helping other nurses if scheduling does not permit it

a. By asking the patient to prioritize what they want to accomplish each day, the nurse is demonstrating an effective time management technique. In order to manage time, the nurse should establish goals and priorities for each day, differentiating "need to do" from "nice to do" tasks; the nurse should include the patient in this process. The nurse should also establish a time line, allocating priorities to hours in the workday in order to keep track of falling behind and correct the problem before the day is lost. The nurse should use teamwork appropriately to enhance the schedule.

A nurse manager who works in a hospital setting is researching the use of energy healing to use as an integrative care practice. Which patient would be the best candidate for this type of CHA? A. A patient who is anxious about residual pain from cervical spinal surgery B. A patient who is experiencing abdominal discomfort C.A patient who has chronic pain from diabetes D. A patient who has frequent cluster headaches

a. Energy healing is focused on pain that lingers after an injury heals, as well as pain complicated by trauma, anxiety, or depression. Nutritional and herbal remedies treat all chronic pain, but especially abdominal discomfort, headaches, and inflammatory conditions, such as rheumatoid arthritis.

A school nurse is providing information for parents of teenagers regarding the human papillomavirus (HPV) and the recommended HPV vaccination. What teaching point would the nurse include? A."HPV causes genital warts and cervical and other genital cancers." B."HPV causes a single painless genital lesion and can lead to sterility." C."50% of women between the ages of 14 and 19 are infected with HPV." D."The HPV vaccination is only recommended for the female population."

a. HPV causes genital warts and cervical and other genital cancers. It manifests as pale, soft, papillary lesions found around the internal and external genitalia and perianal and rectal areas of the body. One in four young women between the ages of 14 and 19 is infected with at least one of the most common STIs, which include the human papillomavirus (HPV). The HPV vaccination is recommended for males and females.

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients? A.Increase physical activities during the day. B.Encourage short periods of napping during the day. C.Increase fluids during the evening. D.Dispense diuretics during the afternoon hours.

a. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.

A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? A.No action is necessary as this is a normal finding during sleep. B. Call the primary care provider to report possible neurologic deficit. C. Lower the temperature in the patient's room. D. Awaken the patient as this is an indication of night terrors.

a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? A.Carefully assessing the patient care environment B.Using two nurses to lift a patient who cannot assist C.Wearing a back belt to perform routine duties D.Properly documenting the patient lift

a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

A nurse is counseling an older couple regarding sexuality. Which statement from the couple should the nurse address? A."We're at the age when we should consider ceasing sexual activity." B."We need more time for sexual stimulation than we used to." C."If we are unable to have sex we can still have an intimate relationship." D."If we change our position we can still have sex and be more comfortable."

a. Sexual activity need not be hindered by age, and couples who have been consistently sexually active throughout their lives may continue their intimate relationship for as long as they desire. Nurses should teach couples that adaptation to bodily changes is possible with use of comfortable positions for intercourse and increased time for stimulation as well as teach alternatives to coitus, such as caressing, hugging, and stroking, when coitus is impossible because of illness or disability.

A patient is being transferred from the ICU to a regular hospital room. What must the ICU nurse be prepared to do as part of this transfer? A. Provide a verbal report to the nurse on the new unit. B. Provide a detailed written report to the unit secretary. C. Delegate the responsibility for providing information. D. Make a copy of the patient's medical record.

a. The ICU nurse gives a verbal report on the patient's condition and nursing care needs to the nurse on the new unit. This information is not given to a unit secretary, nor is its provision delegated to others. The medical record is transferred with the patient; a copy is not made.

An older nurse asks a younger coworker why the new generation of nurses just aren't ethical anymore. Which reply reflects the BEST understanding of moral development? A. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." B. "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" C. "Ethics is genetically determined...it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." D. "I agree! It's impossible to be ethical when working in a practice setting like this!"

a. The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually.

A patient tells the nurse that she would like to use a mechanical barrier for birth control. Which method might the nurse recommend? Diaphragm Oral contraceptive pills Depo-Provera Evra patch

a. The diaphragm is the only barrier method of contraception listed; all the other methods are hormonal.

An attorney is representing a patient's family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse's actions. How should the nurse respond? A. "I'm sorry, but I can't talk with you; you will have to contact my attorney." B. "I will answer your questions so you'll understand how the situation occurred. C. "I hope I won't be blamed for the death because it was so busy that day." D. "First tell me why you are doing this to me. This could ruin my career!"

a. The nurse should not discuss the case with anyone at the facility (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters. This is one of the cardinal rules for nurse defendants.

A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse's commitment to the principle of autonomy? A. The nurse helps the patient prepare a durable power of attorney document. B. The nurse gives the patient undivided attention when listening to concerns. C. The nurse keeps a promise to provide a counselor for the patient. D. The nurse competently administers pain medication to the patient.

a. The principle of autonomy obligates nurses to provide the information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients.

A 17-year-old college student calls the emergency department (ED) and tells the nurse that she was raped by a professor. She wants to come to the ED, but only if the nurse can assure her that they will not call her parents. What should be the nurse's first priority? A.Getting the patient into a safe environment and mobilizing support for her B.Encouraging the student to disclose the name of the professor so that his predatory behavior will be stopped C.Convincing the student to be assessed for pregnancy, STIs, or other complications D.Convincing the student to tell her parents so that she can receive their support

a. While the remaining options may be indicated, the first priority is to ensure the safety of the woman and to get her the support she needs at this moment.

A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe this process? Select all that apply. A.People are born with values. B.Values act as standards to guide behavior. C.Values are ranked on a continuum of importance. D.Values influence beliefs about health and illness. E.Value systems are not related to personal codes of conduct. F.Nurses should not let their values influence patient care.

b, c, d. A value is a belief about the worth of something, about what matters, which acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person's values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture.

A charge nurse in a busy hospital manages a skilled nursing unit using an autocratic style of leadership. Which leadership tasks BEST represent this style of leadership? Select all that apply. A. The charge nurse polls the other nurses for input on nursing protocols. B. The charge nurse dictates break schedules for the other nurses. C. The charge nurse schedules a mandatory in-service training on new equipment. D. The charge nurse allows the other nurses to divide up nursing tasks. E. The charge nurse delegates nursing responsibilities to the staff. F. The charge nurse encourages the nurses to work independently.

b, c, e. Autocratic leadership involves the leader assuming control over the decisions and activities of the group, such as dictating schedules and work responsibilities, and scheduling mandatory in-service training. Polling other nurses is an example of democratic leadership, which is characterized by a sense of equality among the leader and other participants, with decisions and activities being shared. In laissez-faire leadership, the leader relinquishes power to the group and encourages independent activity by group members. Examples of laissez-faire leadership style are allowing the nurses to divide up the tasks and encouraging them to work independently.

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. A. A patient who is taking iron supplements for anemia. B. A patient with Parkinson's disease who is taking dopamine. C. An older adult taking diuretics for congestive heart failure. D. A patient who is taking antibiotics for an ear infection. E. A patient who is prescribed antidepressants. F. A patient who is taking low-dose aspirin prophylactically.

b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply. A. An incident report is used as disciplinary action against staff members. B. An incident report is used as a means of identifying risks. C. An incident report is used for quality control. D. The facility manager completes the incident report. E. An incident report makes facts available in case litigation occurs. F. Filing of an incident report should be documented in the patient record.

b, c, e. Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs; in some states, incident reports may be used in court as evidence. A health care provider completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed.

A nurse is providing health checkups for patients in a clinic located in a predominately LGBT community. Which health disparities should the nurse keep in mind related to this population? Select all that apply. A.LGBT youth are four times more likely to attempt suicide. B.LGBT youth are more likely to be homeless. C.Lesbians are less likely to get preventive services for cancer. D.Lesbians and bisexual females are more likely to be underweight. E.Transgender people have a high prevalence of HIV and sexually transmitted infections. F.LGBT populations have the lowest rates of tobacco, alcohol, and other drug use in the country.

b, c, e. LGBT youth are more likely to be homeless. Lesbians are less likely to get preventive services for cancer. Transgender people have a high prevalence of HIV and sexually transmitted infections. LGBT youth are two to three times more likely to attempt suicide. Lesbians and bisexual females are more likely to be overweight or obese. LGBT populations have the highest rates of tobacco, alcohol, and other drug use in the country. These health issues are partly thought to be the effects of chronic stress resulting from stigmatization.

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. A.Do full-body pushups in bed six to eight times daily. B.Breathe in and out smoothly during quadriceps drills. C.Place the bed in the lowest position or use a footstool for dangling. D.Dangle on the side of the bed for 30 to 60 minutes. E.Allow the nurse to bathe the patient completely to prevent fatigue. F.Perform quadriceps two to three times per hour, four to six times a day.

b, c, f. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

A nurse works for a health care provider who practices the naturopathic system of medicine. What is the focus of nursing actions based on this type of medical practice? Select all that apply. A.Treating the symptoms of the disease B.Providing patient education C.Focusing on treating individual body systems D.Making appropriate interventions to prevent illness E.Believing in the healing power of nature F.Encouraging patients to take responsibility for their own health

b, d, e, f. Naturopathic medicine is not only a system of medicine, but also a way of life, with emphasis on patient responsibility, patient education, health maintenance, and disease prevention. Its principles include minimizing harmful side effects and avoiding suppression of symptoms, educating patients and encouraging them to take responsibility for their own health, treating the whole person, preventing illness, believing in the healing power of nature, and treating the cause of a disease or condition rather than its symptoms.

A nurse who is a discharge planner in a large metropolitan hospital is preparing a discharge plan for a patient after a kidney transplant. Which actions would this nurse typically perform to ensure continuity of care as the patient moves from acute care to home care? Select all that apply. A. Performing an admission health assessment B. Evaluating the nursing plan for effectiveness of care C. Participating in the transfer of the patient to the postoperative care unit D. Making referrals to appropriate facilities E. Maintaining records of patient satisfaction with services F. Assessing the strengths and limitations of the patient and family

b, d, f. The primary roles of the discharge planner as patients move from acute to home care are evaluating the nursing plan for effectiveness of care, making referrals for patients, and assessing the strengths of patients and their families. Although in smaller facilities a discharge planner may perform an admission health assessment and assist with patient transfers, it is not the usual job of the discharge planner. In most facilities, maintaining records of patient satisfaction is the role of the public relations manager or office manager.

A nurse manager is attempting to update a health care provider's office from paper to electronic health records (EHR) by using the eight-step process for planned change. Place the following actions in the order in which they should be initiated: A. The nurse devises a plan to switch to EHR. B. The nurse records the time spent on written records versus EHR. C. The nurse attains approval from management for new computers. D. The nurse analyzes all options for converting to EHR. E. The nurse installs new computers and provides an in-service for the staff. F. The nurse explores possible barriers to changing to EHR. G. The nurse follows up with the staff to check compliance with the new system. H. The nurse evaluates the effects of changing to EHR.

b, f, d, c, a, e, h, g. Planned change involves the following steps: (1) recognize symptoms that indicate a change is needed and collect data, (2) identify a problem to be solved through change, (3) determine and analyze alternative solutions, (4) select a course of action from possible solutions, (5) plan for making the change, (6) implement the change, (7) evaluate the change, and (8) stabilize the change.

A nurse who is working in a hospital setting uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. A. A patient decides to quit smoking following a diagnosis of lung cancer. B. A patient shows off a new outfit that she is wearing after losing 20 pounds. C. A patient chooses to work fewer hours following a stress-related myocardial infarction. D. A patient incorporates a new low-cholesterol diet into his daily routine. E. A patient joins a gym and schedules classes throughout the year. F. A patient proudly displays his certificate for completing a marathon.

b, f. Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts on the value by combining choice and behavior with consistency and regularity, such as joining a gym for the year and following a low-cholesterol diet faithfully.

Review of a patient's record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed? A. Assault B. Battery C. Invasion of privacy D. False imprisonment

b. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? A.A 4-month-old infant who is unable to roll over B.A 6-month-old infant who is unable to hold his head up himself C.An 11-month-old infant who cannot walk unassisted D.An 18-month-old toddler who cannot jump

b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

A nurse manager who is attempting to institute the SBAR process to communicate with health care providers and transfer patient information to other nurses is meeting staff resistance to the change. Which action would be most effective in approaching this resistance? A. Containing the anxiety in a small group and moving forward with the initiative B. Explaining the change and listing the advantages to the person and the organization C. Reprimanding those who oppose the new initiative and praising those who willingly accept the change D. Introducing the change quickly and involving the staff in the implementation of the change

b. Change is ubiquitous, as is resistance to change. The manager should explain the proposed change to all affected, list the advantages of the proposed change for all parties, introduce the change gradually, and involve everyone affected by the change in the design and implementation of the process. The manager should not use the reward/punishment style to overcome resistance to change.

A nurse working in a long-term care facility incorporates aromatherapy into her practice. For which patient would this nurse use the herb ginger? A. A patient who has insomnia B. A patient who has nausea C. A patient who has dementia D. A patient who has migraine headaches

b. Commonly used essential oils in a health care setting are ginger or peppermint for nausea and lavender or chamomile for insomnia.

A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient's doctor threatens the nurse with firing if the nurse raises questions about the patient's care or calls the consult. What ethical conflict is this nurse experiencing? A. Ethical uncertainty B. Ethical distress C. Ethical dilemma D. Ethical residue

b. Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, the nurse fears the loss of job). Ethical uncertainty results from feeling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action. Ethical residue is what nurses experience when they seriously compromise themselves or allow themselves to be compromised.

A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? A."I can expect my newborn to sleep an average of 16 to 24 hours a day." B."If I see eye movements or groaning during my baby's sleep I will call the pediatrician." C."I will place my infant on his back to sleep." D."I will not place pillows or blankets in the crib to prevent suffocation."

b. Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib as it may pose a suffocation risk.

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? A.Supination B.Dorsiflexion C.Hyperextension D.Abduction

b. For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? A.Improved renal blood supply to the kidneys B.Urinary stasis C.Decreased urinary calcium D.Acidic urine formation

b. In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

At a follow-up visit, a patient recovering from a myocardial infarction tells the nurse: "I feel like my life is out of control ever since I had the heart attack. I would like to sign up for yoga, but I don't think I'm strong enough to hold poses for long." What would be the nurse's best response? A."Right now you should concentrate on relaxing and taking your blood pressure medicine regularly, instead of worrying about doing yoga." B."There is a slower-paced yoga called Kripalu that focuses on coming into balance and relaxation that you could look into." C."Ashtanga yoga is a gentle paced yoga that would help with your breathing and blood pressure." D."Yoga is contraindicated for patients who have had a heart attack."

b. Kripalu, or "gentle yoga," focuses on relaxation and coming into balance. Ashtanga focuses on synchronizing breath with a fast-paced series of postures. The nurse should not discourage the use of yoga in patients who are healthy enough to participate. Yoga is not contraindicated in patients with controlled high blood pressure.

A new nurse manager at a small hospital is interested in achieving Magnet status. Which action would help the hospital to achieve this goal? A. Centralizing the decision-making process B. Promoting self-governance at the unit level C. Deterring professional autonomy to promote teamwork D. Promoting evidence-based practice over innovative nursing practice

b. Magnet hospitals use a decentralized decision-making process, self-governance at the unit level, and respect for and acknowledgment of professional autonomy. In Magnet hospitals, 14 characteristics, the Forces of Magnetism, have been recognized that identify quality patient care, excellent nursing care, and innovations in professional nursing practice.

The mother of an 8-year-old boy tells the nurse that she is worried because she has found her son masturbating on occasion. She asks the nurse how she should "handle this problem." What would be the best response of the nurse to this mother's concern? A."Children should be taught not to masturbate because most people believe self-stimulation is wrong." B."Masturbation is a means of learning what a person prefers sexually, and overreacting to it can lead to the child thinking sex is bad or dirty." C."There are serious health risks associated with frequent masturbation, and the practice should be discouraged in children." D."Children who masturbate demonstrate sexual dysfunction and should be seen by a child psychologist."

b. Masturbation is a technique of sexual expression in which a person practices self-stimulation. It is a way for people to learn what they prefer during stimulation and what feels good. The reality is that people masturbate regardless of sex, age, or marital status. People might not masturbate because they feel guilty about it or believe self-stimulation is wrong. Masturbation is not "dirty" and will not lead to blindness or insanity. Negative overreaction by parents to a child's masturbating behavior can lead to a belief that the genitals and sex are bad and dirty.

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? A.Circadian rhythm sleep-wake disorder B.Narcolepsy C.Enuresis D.Sleep apnea

b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? A. Students are not responsible for their acts of negligence resulting in patient injury. B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. C. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student's competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance.

A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute? A. Providing honest information to patients and the public B. Promoting universal access to health care C. Planning care in partnership with patients D. Documenting care accurately and honestly

b. The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honestly are examples of integrity, and planning care in partnership with patients is an example of autonomy.

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? A.Keep the room light dimmed during the day. B.Keep the room cool. C.Keep the door of the room open. D.Offer a sleep aid medication to patients on a regular basis.

b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? A.Use the axillae to bear body weight. B.Keep elbows close to the sides of the body. C.When rising, extend the uninjured leg to prevent weight bearing. D.To climb stairs, place weight on affected leg first.

b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs.

Which statement or question MOST exemplifies the role of the nurse in establishing a discharge plan for a patient who has had major abdominal surgery? A. "I'll bet you will be so glad to be home in your own bed." B. "What are your expectations for recovery from your surgery?" C. "Be sure to take your pain medications and change your dressing." D. "You will just be fine! Please stop worrying."

b. The purpose of planning for continuity of care, commonly referred to in hospitals and community facilities as discharge planning, is to ensure that patient and family needs are consistently met as the patient moves from a care setting to home. Essential components of discharge planning include assessing the strengths and limitations of the patient, the family or support person, and the environment; implementing and coordinating the care plan; considering individual, family, and community resources; and evaluating the effectiveness of care. Answers a and c are not MOST reflective of the role of the nurse in discharge planning, although teaching and communication are elements of this process. The statement "You will just be fine! Please stop worrying." is a cliché and should not be used.

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? A.2 B.4 C.5 D.6

b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

A home health care nurse is scheduled to visit a 38-year-old woman who has been discharged from the hospital with a new colostomy. Which duties would the nurse perform for this patient in the entry phase of the home visit? Select all that apply. A. Collect information about the patient's diagnosis, surgery, and treatments. B. Call the patient to make initial contact and schedule a visit. C. Develop rapport with the patient and her family. D. Assess the patient to identify her needs. E. Assess the physical environment of the home. F. Evaluate safety issues including the neighborhood in which she lives.

c, d, e. In the entry phase of the home visit, the nurse develops rapport with the patient and family, makes assessments, determines nursing diagnoses, establishes desired outcomes, plans and implements prescribed care, and provides teaching. In the pre-entry phase of the home visit, the nurse collects information about the patient's diagnoses, surgical experience, socioeconomic status, and treatment orders. In the pre-entry phase, the nurse also gathers supplies needed, makes an initial phone contact with the patient to arrange for a visit, and assesses the patient's environment for safety issues.

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. A.He is aware of his surroundings at this point. B.He is in delta sleep at this time. C.It would be most difficult to awaken him at this time. D.This is most likely an NREM stage. E.This stage constitutes around 20% to 25% of total sleep. F.The muscles are relaxed in this stage.

c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: A.Grasp the gait belt. B.Stay with the patient and call for help. C.Place feet wide apart with one foot in front. D.Gently slide patient down to the floor, protecting her head. E.Pull the weight of the patient backward against your body. F.Rock your pelvis out on the side of the patient.

c, f, a, e, d, b. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help.

A nurse is preparing an infant and his family for a hernia repair to be performed in an ambulatory care facility. What is the primary role of the nurse during the admission process? A. To assist with screening tests B. To provide patient teaching C. To assess what has been done and what still needs to be done D. To assist with hernia repair

c. Although all the actions may be performed by the ambulatory care nurse, it is the nurse's primary responsibility to assess what has been done and to tailor the care plan to the patient's needs. Screening tests and teaching are usually completed before the patient enters an ambulatory care facility.

A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? A. Accreditation B. Licensure C. Certification D. Board approval

c. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing.

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? A.The use of a central nervous system stimulant B.Continuous positive airway pressure machine (CPAP) C.Chronotherapy D.The application of heat or cold therapy to promote sleep

c. Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central nervous system stimulant is recommended for narcolepsy. Continuous positive airway pressure machine (CPAP) is used for OSA, and the application of heat or cold therapy to the legs is used to treat RLS.

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? A.Dorsal recumbent position B.Lateral position C.Fowler's position D.Sims' position

c. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain.

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? A.Wait a few minutes and then continue the move to the chair. B.Call for assistance and continue the move with the help of another nurse. C.Lower the patient back to the side of the bed and pivot her back into bed. D.Have the patient sit down on the bed and dangle her feet before moving.

c. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position.

A nurse is providing a lecture on CHAs to a group of patients in a rehabilitation facility. Which teaching point should the nurse include? A.CHAs are safe interventions used to supplement traditional care. B.Many patients use CHA as outpatients but do not wish to continue as inpatients. C.Many nurses are expanding their clinical practice by incorporating CHA to meet the demands of patients. D.Most complementary and alternative therapies are relatively new and their efficacy has not been established.

c. Many nurses are expanding their clinical practice by incorporating CHA. Although CHA may seem totally safe, some therapies have led to harmful and, at times, lethal outcomes. Many patients use these types of therapies as outpatients and want to continue their use as inpatients. Although the use of most complementary and alternative therapies predates modern medicine, it was not until recently that nursing and medical schools began to teach about their use.

A nurse is guiding a patient in the practice of meditation. Which teaching point is most useful in helping the patient to achieve a state of calmness, physical relaxation, and psychological balance? A.Teach the patient to always lie down in a comfortable position during meditation. B.Teach the patient to focus on multiple problems that the patient feels demand attention. C.Teach the patient to let distractions come and go naturally without judging them. D.Teach the patient to suppress distracting or wandering thoughts to maintain focus.

c. Meditators should have an open attitude by letting distractions come and go naturally without judging them. They should also maintain a specific, comfortable posture lying down, sitting, standing, walking, etc.; focus attention on a mantra, object, or breathing; and not suppress distracting or wandering thoughts; instead they should gently bring attention back to focus.

A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? A. Preparing the family for a diagnosis of insomnia and related treatments. B. Preparing the family for a diagnosis of narcolepsy and related treatments. C. Anticipating the scheduling of polysomnography to confirm OSA. D. No action would be taken, as this is a normal finding for hospitalized children.

c. OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of Pediatrics children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. This scenario is not usually a normal finding in hospitalized children during sleep.

An 18-year-old presents at a women's health care clinic seeking oral contraceptives for the first time. She tells the nurse that she wants to have sex with her boyfriend, but doesn't know what to expect. Which statement by the nurse is not accurate? A."Vaginal intercourse is most commonly performed in the missionary position." B."The side-by-side position achieves better clitoral stimulation than the missionary position." C."Achieving simultaneous orgasms is the goal of vaginal intercourse." D."The period after coitus is just as significant as the events leading up to it."

c. Simultaneous orgasms, or both people attaining orgasm at the same moment, are difficult to achieve, and a preoccupation with attaining simultaneous orgasms might disrupt the ultimate intimacy and satisfaction possible during coitus. The most common position in Western cultures is the "missionary position," in which the woman lies horizontally underneath the man. Clitoral stimulation is difficult to achieve in the missionary position. Lying side by side, female on top, and rear entry are some examples of coital positions that enable clitoral stimulation. The period after coitus is just as significant as the events leading up to it.

A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? A.Drinking a cup of regular tea at night induces sleep. B.Using alcohol moderately promotes a deep sleep. C.Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. D.Exercising right before bedtime can hinder sleep.

c. The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.

A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. What is the term for those bringing the charges against the nurse? A. Appellates B. Defendants C. Plaintiffs D. Attorneys

c. The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant.

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? A.Have the patient extend his arms outward and cross his legs on top of a pillow. B.Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. C.Have the patient cross his arms on his chest and place a pillow between his knees. D.Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

A nurse is assessing a patient who is visiting her gynecologist. The patient tells the nurse that she has been having a vaginal discharge that "smells bad and is green and foamy." She also complains of burning upon urination and dyspareunia. What sexually transmitted infection would the nurse suspect? A.Human papillomavirus (HPV) B.Syphilis C.Trichomoniasis D.Herpes simplex virus

c. Trichomoniasis causes a foul-smelling vaginal discharge that is thin, foamy, and green in color, and also causes itching of the vulva and vagina, burning on urination, and dyspareunia. HPV causes a profuse watery vaginal discharge, dyspareunia, intense pruritus, and vulvar irritation. Syphilis causes a single painless genital lesion 10 days to 3 months after exposure and generalized skin rash, enlarged lymph nodes, and fever that may appear 2 to 4 weeks after appearance of primary lesion and may last for several years. Herpes presents as single or multiple painful vesicles that rupture and form ulcer-like lesions, which form scabs as they heal.

A patient tells the nurse counselor that he can only get sexual pleasure by looking at the body of a person other than his wife from a distance. How would the nurse document this data? A.Masochism B.Pedophilia C.Voyeurism D.Sadism

c. Voyeurism is the achievement of sexual arousal by looking at the body of someone other than a person's own sexual partner. Masochism refers to gaining sexual pleasure from the humiliation of being abused. Pedophilia is a term used to describe the practice of adults gaining sexual fulfillment by performing sexual acts with children. Sadism refers to the practice of gaining sexual pleasure while inflicting abuse on another person.

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. A.REM sleep constitutes much of the sleep cycle of a preschool child. B.By the age of 8 years, most children no longer take naps. C.Sleep needs usually decrease when physical growth peaks. D.Many adolescents do not get enough sleep. E.Total sleep decreases in adults with a decrease in stage IV sleep. F.Sleep is less sound in older adults and stage IV sleep may be absent.

d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.

A nurse ensures that a hospital room prepared by an aide is ready for a new ambulatory patient. Which condition would the nurse ask the aide to correct? A. The bed linens are folded back. B. A hospital gown is on the bed. C. Equipment for taking vital signs is in the room. D. The bed is in the highest position.

d. A properly prepared hospital room includes a bed in the lowest position for an ambulatory patient, an open bed with top linens folded back, routine equipment and supplies and special equipment and supplies assembled, and the physical environment of the room adjusted.

A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? A.Public law B.Private law C.Civil law D.Criminal law

d. Criminal law concerns state and federal criminal statutes, which define criminal actions such as murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry.

Which assessment question would be most appropriate for a patient who is experiencing dyspareunia? A."Do you currently have a new partner?" B."Have you been diagnosed with a neurologic disorder?" C."Do you take antihypertensive medication?" D."Do you use antihistamines?"

d. Factors contributing to dyspareunia include diabetes; hormonal imbalances; vaginal, cervical, or rectal disorders; antihistamine, alcohol, tranquilizer, or illicit drug use; and cosmetic or chemical irritants to genitals.

A nurse is caring for a postoperative patient who is experiencing pain. Which CHA might the nurse use to ensure active participation by the patient to achieve effective pre- or postoperative pain control? A.Acupuncture B.TT C.Botanical supplements D.Guided imagery

d. Imagery involves using all five senses to imagine an event or body process unfolding according to a plan. A patient can be encouraged to "go to a favorite place." With the other modalities, the patient is more passive.

A veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? A. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. B. The fact that this patient should not have died since she was a healthy grandmother of 10, who was physically active and involved in her community. C. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome of routine hernia surgery. D. The nurse had a duty to monitor the patient's vital signs, and due to the nurse's failure to perform this duty in this circumstance, the patient died.

d. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient.

A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? A. The nurse is not responsible, because the nurse was following the doctor's orders. B. Only the nurse is responsible, because the nurse actually administered the medication. C. Only the health care provider is responsible, because the health care provider actually ordered the drug. D. Both the nurse and the health care provider are responsible for their respective actions.

d. Nurses are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. If the nurse should have anticipated injury and did not, both the prescribing health care provider and the administering nurse are responsible for the harms to which they contributed.

A school nurse is providing sex education classes for adolescents. Which statement by the nurse accurately describes normal sexual functioning? A."Each person is born with a certain amount of sexual drive, which can be depleted in later years." B."If you want to be a great athlete, sexual abstinence is necessary when you are training." C."If you have a nocturnal emission (wet dream), it is an indicator of a sexual disorder." D."It is natural for a woman to have as strong a desire for sex and enjoy it as much as a man."

d. Physiologic studies indicate that, in some respects, the woman's sex drive is not only as strong but may be even stronger than that of the man. The more consistently sexually active a person is, the longer the activity continues into the later years of life. Physiologically, the achievement of orgasm is rarely more demanding than most activities encountered in daily life; there is no scientific evidence that sex "weakens" a person. Erotic dreams that culminate in orgasms are normal common physiologic phenomena in at least 85% of men.

A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? A. Altruism B. Autonomy C. Human dignity D. Integrity

d. The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations.

A nurse manager of a busy cardiac unit observes disagreements between the RNs and the LPNs related to schedules and nursing responsibilities. At a staff meeting, the manager compliments all the nurses on a job well done and points out that expected goals and outcomes for the month have been met. The nurse concludes the meeting without addressing the disagreements between the two groups of nurses. Which conflict resolution strategy is being employed by this manager? A. Collaborating B. Competing C. Compromising D. Smoothing

d. The manager who resolves conflict by complimenting the parties involved and focusing on agreement rather than disagreement is using smoothing to reduce the emotion in the conflict. The original conflict is rarely resolved with this technique. Collaborating is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. Competing results in a win for one party at the expense of the other group. Compromising occurs when both parties relinquish something of equal value.

A hospital nurse is admitting a patient who sustained a head injury in a motor vehicle accident. Which activity could the nurse delegate to licensed assistive personnel? A. Collecting information for a health history B. Performing a physical assessment C. Contacting the health care provider for medical orders D. Preparing the bed and collecting needed supplies

d. The nurse may delegate preparation of the bed and collection of needed supplies to unlicensed personnel but would perform the other activities listed.

A nurse is counseling an older woman who has been hospitalized for dehydration secondary to a urinary tract infection. The patient tells the nurse: "I don't like being in the hospital. There are too many bad bugs in here. I'll probably go home sicker than I came in." She also insists that she is going to get dressed and go home. She has the capacity to make these decisions. What is the legal responsibility of the nurse in this situation? A. To inform the patient that only the primary health care provider can authorize discharge from a hospital B. To collect the patient's belongings and prepare the paperwork for the patient's discharge C. To request a psychiatric consult for the patient and inform her PCP of the results D. To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form

d. The patient is legally free to leave the hospital AMA; however, patients who leave the hospital AMA must sign a form releasing the health care provider and hospital from legal responsibility for their health status. This signed form becomes part of the medical record.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? A.Side-lying B.Fowler's C.Sims' D.Prone

d. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.

A pediatric nurse is assessing a 5-year-old boy who has dietary modifications related to his diabetes. His parents tell the nurse that they want him to value good nutritional habits, so they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? A.Modeling B.Moralizing C.Laissez-faire D.Rewarding and punishing

d. When rewarding and punishing are used to transmit values, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Through modeling, children learn what is of high or low value by observing parents, peers, and significant others. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Those who use the laissez-faire approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system.

A nurse is teaching patients about contraception methods. Which statement by a patient indicates a need for further teaching? A."Depo-Provera is not effective against sexually transmitted infections, but contraceptive protection is immediate if I get the injection on the first day of my period." B."The hormonal ring contraceptive, NuvaRing, protects against pregnancy by suppressing ovulation, thickening cervical mucus, and preventing the fertilized egg from implanting in the uterus." C."Abstinence is an effective method of contraception and may be used as a periodic or continuous strategy to prevent pregnancy and STIs." D."Withdrawal is an effective method of birth control as well as an effective method of reducing the spread of sexually transmitted infections."

d. Withdrawal offers no protection against sexually transmitted infections. An injection of DMPA in the buttock or arm can prevent pregnancy for 12 weeks and is 99.7% effective. Protection is immediate if the injection is given on the first day of the woman's period. The NuvaRing works by inhibiting ovulation in much the same way as oral contraceptives. Used appropriately, the vaginal ring is 99.3% effective in protecting against pregnancy. Abstinence is the most effective form of birth control, preventing pregnancy 100% of the time when practiced consistently. Abstinence also prevents the transmission of STIs 100% of the time when practiced appropriately and consistently.

A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse's action reflects which principle of bioethics? A. Autonomy B. Beneficence C. Justice D. Fidelity E. Nonmaleficence

e. Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another's right to make decisions, beneficence obligates us to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises.

A nurse uses Therapeutic Touch (TT) to decrease a postoperative client's nausea. What CAM principle does this modality reflect?

Illness is an imbalance in a person's energy field.

A client who is taking an oral narcotic for pain relief tells the nurse he is constipated. What is this common response to narcotics called?

adverse effect

A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asked the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations. B. Location of the pain. C. Pain quality. D. Aggravating and relieving factors.

A. Attempt to identify manifestations that occur along with the client's pain (nausea, fatigue, or anxiety).

The nurse is assisting the client who has dementia from the bed to the chair for mealtime. What actions by the nurse would facilitate cooperation from the client?

A. Call the client by the preferred name. B. Face the client when speaking. C. Provide instructions one at a time. D. Be positive in statements when providing instructions.

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply.) A. REM sleep provides cognitive restoration. B. REM sleep lasts about 90 min. C. It is difficult to awaken a person REM sleep. D. Sleepwalking occurs during REM sleep. E. Vivid dreams are common during REM sleep.

A. Cognitive and brain tissue restoration occur during REM sleep. C. In this stage, awakening is difficult. Awakening is relatively easy and stages 1 and 2 of non-REM sleep. E. Dreaming does occur in other stages but it is less vivid and possibly less colorful.

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) A. The client who has terminal cancer request hospice care in the home. B. A client asks about community resources available for older adults. C. A client states, "I would like to have my child baptized before surgery." D. A client request an electric wheelchair for use after discharge. E. A client states, "I do not understand how to use a nebulizer."

A. Initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a client. B. Initiate a referral for a social worker to provide information and assistance in coordinating care for community resources available for clients. D. Initiate a referral for a social worker to assist client in obtaining medical equipment for use after discharge.

A nurse is acquainting a group of newly licensed nurses with the rules of the various members of the healthcare team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNA) can perform, which of the following client activity should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

A. It is within the range of function for a CNA to provide basic care to clients (bathing). B. It is within the range of function for a CNA to provide basic care to clients (assisting with ambulation) C. It is within the range of function for a CNA to provide basic care to clients (assisting with toileting). E. It is within the range of function for a CNA to provide basic care to clients (measuring and recording vital signs)z

A nurse in a providers office is caring for a client who states that for the past week, "I have felt tired during the day and cannot sleep at night." Save the following responses should the nurse ask when collecting data about the clients difficulty sleeping? (Select all that apply.) A. "Have your working hours changed recently?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee tea or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing?"

A. Job changes including roles and working hours can affect the quality and quantity of sleep. C. Caffeinated drinks act as a stimulant and can interfere with sleep. D. Periods of apnea warrant a prompt referral for diagnostic sleep studies. E. Emotional stress is a common cause of short-term sleep problems.

The client states to the nurse, "I don't know what they're doing for me. I see so many doctors. One says one thing, another says something else." What are appropriate actions by the nurse to assist the client in understanding the plan of care?

A. Make rounds with health care professionals when visiting the client. B. Restate recommendations in simple terms that the client will understand. C. Read the consultation and progress notes written by health care professionals. E. Assist the client to identify and write questions for the health care professionals.

A nurse is talking with the client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply?) A. Practice muscle relaxation techniques. B. Exercise each morning. C. Take an afternoon nap. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime.

A. Relaxation techniques especially muscle relaxation can help promote sleep and rest. B. Following an exercise routine regularly at least two hours prior to bedtime can help promote rest and sleep. D. For example rather than trying to sleep with the restless pet at the foot of the bed, move the pet to another sleep area. E. Limiting fluids for a few hours before bedtime helps minimize getting up to urinate.

The nurse triaged a number of clients in the emergency department. Which clients would the nurse identify as Risk for Infection?

A. The client who has AIDS and is taking antiretroviral medications B. The client who reports abdominal pain for 1 day and exhibits an elevated white blood cell count C. The client who has breast cancer, is receiving chemotherapy, and is low white blood cell (WBC) count D. The older adult client who is cachetic in appearance

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their position.

A. The first action to take using the nursing process is to assess or collect data from the client. Therefore the priority action is to determine the clients fall risk. This will work as a guide and implementing appropriate safety measures.

An RN on a surgical unit is behind schedule administering medications. Which of the RN's other tasks can be safely delegated to a UAP? A. The assessment of a patient who has just arrived on the unit B. Teaching a patient with newly diagnosed diabetes about foot care C. Documentation of a patient's I & O on the flow chart D. Helping a patient who has recently undergone surgery out of bed for the first time

An RN on a surgical unit is behind schedule administering medications. Which of the RN's other tasks can be safely delegated to a UAP? The assessment of a patient who has just arrived on the unit Teaching a patient with newly diagnosed diabetes about foot care Documentation of a patient's I & O on the flow chart c. Documenting a patient's I & O on a flow chart may be delegated to a UAP. Professional nurses are responsible for the initial patient assessment, discharge planning, health education, care planning, triage, interpretation of patient data, care of invasive lines, administering parenteral medications. What they can delegate are assistance with basic care activities (bathing, grooming, ambulation, feeding) and things like taking vital signs, measuring intake and output, weighing, simple dressing changes, transfers, and post mortem care.

Nurse manager is assigning care of a client who is being admitted from a PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Charge nurse B. Registered nurse (RN) C. Practical nurse (PN) D. Assistive personnel (AP)

B. A client who is postoperative following thoracic surgery requires professional nursing knowledge, skills, and judgment of an RN to provide safe and effective client care.

A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day."

B. Clients who have narcolepsy should take short naps to reduce feelings of drowsiness.

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side? B. "I will go to the nurses' station for assistance." C. "I will note the time that the seizure begins." D. " I will prepare to insert an airway."

B. During a seizure stay with client and use the call light to summon assistance.

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances

B. The right supervision and evaluation is one of the five rights of delegation. They also include the right task and the right person. C. Right direction and communication is one of the five rights of delegation. They also include the right task and the right person. E. The correct circumstances is one of the five rights of delegation. They also include the right task in the right person.

A nurse is delegating the ambulation of a client who had knee arthroplasty five days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates wearing slippers over antiembolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this morning.

B. To complete this assignment safely, the AP should make sure the client wear stockings and slippers. C. To complete this assignment safely the AP should make sure the client uses a front-wheeled walker. D. To complete this assignment safely, the AP should know that the client should be feeling the effects of the pain medication.

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the ned in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

C. Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. Nonskid footwear keeps the client from slipping. E. A fall-risk assessment serves as a basis for a plan of care that can then individualize for the client.

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C. Opioid and analgesia can cause respiratory depression which causes respiratory rates to drop to dangerously low levels. Monitor the clients respiratory rate and administer naloxone if indicated. D. Opioid analgesia can cause orthostatic hypotension. Monitor for dizziness or lightheadedness when changing positions. E. Opioid analgesia can cause nausea and vomiting. Monitor for and treat these complications as needed.

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I'm sleeping."

C. PCA allows the client to self administer pain medication on as-needed basis. The provider can modify the PCA settings if needed to ensure the client achieves adequate pain relief.

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about location location of the pain. C. Offer the client a pain scale to measure their pain. D. Use open-ended questions identify the clients pain sensations.

C. Use a pain rating scale to help the client report the intensity of the pain. The nurse should use a numeric, verbal, or visual analog scale appropriate to the client's individual needs.

A nurse is caring for a client who has been following the facilities routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Run the clients back for 15 min before bedtime. B. Offer the client warm milk and crackers at 2100. C. Allow the client to take a bath in the evening. D. As the provider for a sleeping medication.

C. When providing care, first use the least restrictive intervention. Of these options, allowing the client to follow their usual bedtime routine represents the least change, so it is the first intervention to try.

An older adult client has lost significant muscle mass during recovery from a systemic infection. As a result, there has been no progress toward meeting any of the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation?

Continue the plan of care with the aim of helping the client achieve the outcomes.

A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse is caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist

D. A speech-language pathologist can initiate specific therapy for client who have difficulty with feeding due to swallowing difficulties.

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse is caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist

D. An occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities.

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the door to the client's room.

D. Please wet towels along the base of the door to the clients room to contain the fire and smoke in the room.

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports pain. B. A client who has incisional pain 72 hr following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall two years ago.

D. The client reports pain that last more than six months and continues beyond the time for tissue healing is experiencing chronic pain. Assist with planning interventions to relieve manifestations associated with the pain.

Then nurse is caring for single, professional woman age 29 years, who was admitted with a severe gall bladder attack. The nurse visits with her and performs an assessment. The client is not married and fears a committed relationship because of a bad experience some years ago. According to Erikson's developmental theory, Judith is in danger of what?

Isolation

Which client would be most at risk for alterations in oral health?

Man with a nasogastric tube

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? A.Support weight on stronger leg and cane and advance weaker foot forward. B.Hold the cane in the same hand of the leg with the most severe deficit. C.Stand with as much weight distributed on the cane as possible. D.Do not use the cane to rise from a sitting position, as this is unsafe.

The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

To promote sleep in a patient, a nurse suggests what intervention? A.Follow the usual bedtime routine if possible. B.Drink two or three glasses of water at bedtime. C.Have a large snack at bedtime. D.Take a sedative-hypnotic every night at bedtime.

a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

A nurse is asked to act as a mentor to a new nurse. Which nursing action is related to this process? A. The nurse mentor accepts payment to introduce the new nurse to his or her responsibilities B. The nurse mentor hires the new nurse and assigns duties related to the position C. The nurse mentor makes it possible for the new nurse to participate in professional organizations D. The nurse mentor advises and assists the new nurse to adjust to the work environment of a busy emergency department

d. Mentorship is a relationship in which an experienced person (the mentor) advises and assists a less experienced person (protégé). This is an effective way of easing a new nurse into leadership responsibilities. An experienced nurse who is paid to introduce an employee to new responsibilities through teaching and guidance describes a preceptor, not a mentor. The nurse mentor does not hire or schedule new nurses. Nurses do not need mentors to join professional organizations.