NRS 200 EXAM 4

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Explanation: Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which of the following questions should she ask?

"Do you work around loud noises at work?" Explanation: Clients may be at risk for sensory disturbances for different reasons. Lifestyle factors include work or leisure activities that are potentially harmful to the eyes and ears, such as loud noises. Physiologic factors, such as diabetes and use of medications (chemotherapy), place clients at risk for sensory disturbances as well. Social and environmental factors include human and environmental stimulation (living by oneself).

While the nurse is assessing an older adult client, which statement by the client requires further investigation?

"I need to go back to my room." Explanation: The client expresses the need to return to their room but they have forgotten that they are in their room. This should alert the nurse of a mental status change. Mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills, can be collected during the client history. Telling the nurse that they can only sleep with lights off is appropriate. Asking when a test is scheduled or when the client's son will visit are normal questions.

A nurse has just finished a presentation to a group of unlicensed assistive personnel (UAP) on ways to assist clients with sensory perception issues, such as low vision or hearing. Which statement by a UAP suggests a need for further education?

"I will move the furniture around depending on what activities are planned for the day." Explanation: Examples of sensory aids include using large print materials; bright, contrasting colors in the environment; uncluttered environment with no furniture rearranging; speaking slowly and distinctly while standing directly in front of the client; and keeping fresh flowers in the room.

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." Explanation: The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care." Explanation: Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?

"Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange. Add a Note

A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client:

"The air is thicker or more viscous with humidity, thus it is harder for you to breathe." Explanation: People with chronic respiratory diseases often find breathing more difficult when the weather is hot and humid because humidity contributes to air viscosity.

An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement?

"What makes you think the food is poisoned?" Explanation: The client is exhibiting delusional behavior. Delusions are beliefs not based on reality that reflect an unconscious need or fear. By asking an open-ended question the nurse can determine why the client is making the statement and create a strategy to change the client's perspective. Asking the client if he or she wants another meal or bringing the client another meal does not address the underlying issue. Telling the client it is okay to eat the meal is not recognizing the client's fear and could damage the nurse-client relationship.

The health care provider has ordered a cold ice bag to be applied to the wrist of a client with a sprain. The nurse will ensure that the cold application is at what temperature before application?

10°-18.3° C (50°-65° F) Explanation: Cold applications should be between 10° and 18.3° C (50°-65° F). An application of 26.6° to 33.8° C (80°-93° F) is tepid; 18.3°- 26.6° C (65°-80° F) is cool; below 10° C (below 50° F) is very cold.

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around:

34 to 36 weeks. Explanation: Surfactant is formed in utero around 34 to 36 weeks. An infant born prior to 34 weeks may not have sufficient surfactant produced, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli.

A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?

80 to 150 mm Hg Explanation: When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150 mm Hg. This level will provide enough pressure to suction out secretions from the endotracheal tube.

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart. Explanation: Among the provisions of HIPAA are clients' rights to see and read their medical records. Negotiation with an insurance provider, the necessity of a second opinion, and out-of-state care are aspects of care that fall within the specific auspices of HIPAA.

In which client should the nurse prioritize assessments for respiratory depression?

A client taking opioids for cancer pain Explanation: Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system.

For which client would the application of a hydrocolloid dressing be most appropriate?

A client who has a partial-thickness venous ulcer with moderate drainage Explanation: Hydrocolloids are occlusive or semiocclusive dressings that limit exchange of oxygen between wound and environment; they are appropriate for partial- and full-thickness wounds with light to moderate drainage. A sunburn would not normally warrant this type of wound dressing and they are not used on infected wounds. Hydrocolloid dressings are not used on uncomplicated surgical incisions.

Which is not a lifespan consideration for sensory perception?

A newborn's sensory perception is very refined. Explanation: A newborn's sensory perception is rudimentary. Newborns see only gross patterns of light and dark or bright colors

An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor?

Adipose tissue is poorly vascularized. Explanation: Wound healing may be decreased in obese clients. Because adipose tissue is relatively avascular, it provides only a weak defense against microbial invasion and impairs delivery of nutrients to the wound.

An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next?

Analyze and Plan Explanation: Evaluation may be the last phase of the system development lifecycle, but it represents an essential step for nurses to be involved in before circling back to Analyze and Plan based on the results of the evaluation. This step is important to complete before making updates or improvements to a system already in place. Once this step is completed, the other steps of the system development lifecycle would follow.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

Be sure to shake the canister before using it. Explanation: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication.

What is the primary purpose of the client record?

Communication Explanation: Patient records serve many purposes., but the ANA states that the most important of these is "communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities" (ANA, 2010, p. 5). Thus communication with the health care team is a more important purpose of documentation than advocacy, research, or education.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?

Crackles in the lower lobes Explanation: People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

Which action should the nurse perform when applying negative pressure wound therapy?

Cut foam to the shape of the wound and place it in the wound. Explanation: When applying a negative pressure dressing, a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician, rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

Depression Sleeplessness Decreased interest in activities Explanation: Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The client who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as depression mounts, leading to further sensory deprivation.

A client is admitted to the intensive care unit. Which way can the nurse decrease sensory overload in this unit?

Explain unfamiliar procedures to the client. Explanation: Severe sensory alterations can occur when a client is admitted to a health care agency, especially in certain areas such as intensive care units (termed intensive care unit [ICU] psychosis). By explaining unfamiliar procedures the client will have a better chance of avoiding sensory overload. In most cases a client in an ICU will be too ill for a tour. The client should be instructed to use the call light, but preventative explanation will be most effective.

A child 4 years of age has a mother who is employed and works from home. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon this information, what nursing diagnosis would be applicable to this family?

Impaired Parenting associated with failure to provide stimuli for growth Explanation: Based upon lack of stimuli (sensory deprivation), an appropriate nursing diagnosis is Impaired Parenting associated with failure to provide stimuli for growth. There is no information that states the child has impaired senses, sensory overload, or impaired skin integrity

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter. Ineffective breathing pattern is the state in which a person's inspiration and/or expiration pattern does not provide adequate ventilation.

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.

Nasal cannula Simple oxygen mask Partial rebreather mask Explanation: Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22%-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40%-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Explanation: With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration. Approximating the wound edges and applying wound closure tapes may cause the client undue pain and trap bacteria in the wound. Irrigating the open wound may cause unwanted bacteria from the surrounding area to wash into the wound.

The 85-year-old female client has become increasingly confused while reviewing the vital sign readings. Which reading might contribute to the client's behavior?

Oxygen saturation of 88% on room air Explanation: Confusion can be linked to hypoxemia or low oxygen level in the body. Other signs and symptoms include restlessness, headache, shortness of breath, and rapid breathing.The blood pressure of 101/56 is within normal limits of less than 140/90. The heart rate is 101 and the normal is 60-120. The temperature is 99.2 and normal is less than 100.4.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

Pleural effusion Explanation: Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

Which are uses of documentation in client records? Select all that apply.

Quality improvement Research Decision analysis Financial reimbursement Explanation: Quality improvement, research, decision analysis, and financial reimbursement are all uses for documentation. Market cost analysis and predictive outcome documentation are not uses for documentation.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Rapid respirations Explanation: Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

A child with special needs has been placed in a classroom with other children with special needs. The classroom is noisy with a high level of activity, and the child appears to have difficulty concentrating on work. Which should the nurse recommend to address the needs of this child?

Relocate the child to a quiet, less chaotic environment to decrease sensory overload. Explanation: Sensory overload is the condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli. By relocating the child to a quiet area the child should have better focus. Sensory deprivation results when a person experiences decreased sensory input. Sensory perception is the conscious process of selecting, organizing, and interpreting data from the senses. Sensory reception is the process of receiving data about the internal and external environment through the senses.

A cycling accident has resulted in a head injury to a client with resultant increased intracranial pressure. Consequently, the client has been placed in a private room with low light and care has been organized to minimize disturbances. What situation is the client most likely at risk for?

Sensory Deprivation Explanation: A care environment that is deliberately organized to minimize stimulation can create a risk of sensory deprivation. A client with a head injury should have a reduced sensory environment to keep intracranial pressure lower and decrease potential complications. Confusion, acute or chronic, are considered complications related to increased intracranial pressure and changes in oxygenation.

A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation?

Source-oriented Explanation: A source-oriented record is a paper format in which each health care group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record. Problem-oriented medical record (POMR) or problem-oriented record is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. PIE charting system is unique in that it does not develop a separate care plan. The care plan is incorporated into the progress notes, which identify problems by number (in the order they are identified). In this documentation system, a client assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets). Client problems identified in these assessments are numbered, documented in the progress notes, worked up using the problem, intervention, evaluation (PIE) format, and evaluated each shift. Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

The nurse is caring for a client who sustained a traumatic brain injury in a skiing accident. The client is breathing independently, drowsy, but arousable with extreme or repeated stimuli. How will the nurse document the client's level of consciousness ?

Stupor Explanation: When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

Submitting a written notice to all clients identifying the uses and disclosures of their health information Explanation: Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

What is the action of codeine when used to treat a cough?

Suppressant Explanation: Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

The nurse is counseling an elderly client. Because of the client's age, the nurse recognizes that she is at risk for macular degeneration. Which of the following is a priority nursing intervention?

Teach the client signals of serious eye problems, such as visual disturbances. Explanation: The most common cause of legal blindness in the elderly is macular degeneration. The first priority is to teach client self-care behaviors for maintaining vision and preventing blindness. Teaching would include knowing the danger signals that indicate serious eye problems. Orienting the client to sounds in the environment would be used for clients who have reduced vision. Avoiding excessive noise is health teaching to prevent hearing loss, and encouraging them to visit the dentist would help to prevent gustatory decline.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

A nurse has applied a transparent dressing to the coccyx of a client who has been immobilized due to a stroke. What purpose is served by this wound product?

The dressing allows oxygen exchange between the wound and environment. Explanation: Transparent films allow for oxygen exchange between the wound and the environment. They do not absorb any drainage and they are normally left in place for up to 72 hours. Sterility is not conferred simply by the application of a wound dressing.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions. Explanation: Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care. Explanation: A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Explanation: Guidelines to determine suction catheter depth include the following: Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply.

inaccurate perception of sights, sounds, tastes, and smells inability to control direction of thought content difficulty with memory, problem solving, and task performance Explanation: Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. Common conditions that result from sensory deprivation include inaccurate perception of sights, sounds, tastes, and smells; inability to control the direction of thought; and difficulty with memory, problem solving, and performing tasks. Decreased coordination and equilibrium, lack of a caring attitude, and unstable moods are also common conditions associated with sensory deprivation.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

limiting abbreviations to those approved for use by the institution. Explanation: In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

milia. Explanation: Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?

pattern of thoracic expansion Explanation: The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:

pneumonia. Explanation: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.

A client who is blind is said to be experiencing:

sensory deficit. Explanation: Impaired or absent functioning in one or more senses, such as blindness, is termed sensory deficit. Sensory overload is excessive stimulation of one or more of the senses. Sensory deprivation is insufficient stimulation of one or more of the senses. Sensory overstimulation is not a common term used in health care.

A client has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the client. When the physician leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing:

sensory overload. Explanation: Sensory overload occurs when a person is unable to process or manage the intensity or quantity of incoming sensory stimuli. Imparting information to a client may lead to sensory overload. Some examples include educating a client on a procedure, informing a client about a diagnosis, making requests of a client, or helping the client solve a problem.

A client has expressed great relief at the improvement in their hearing after irrigation of the ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to:

sensory reception. Explanation: Impacted cerumen is an example of a sensory disturbance that is rooted in interference with the client's reception of stimuli. In this case, sound is unable to stimulate the organs of hearing and the client does not have a deficit in the perception, transmission, or reaction to sound. Sensory perception of pain would come from temperature, mechanical, electrical or chemical stimuli. Sensory transmission occurs by a nerve that passes impulses from receptors toward or to the central nervous system through the afferent nerve and the dorsal root that passes dorsally to the spinal cord and that consists of sensory fibers. A sensory reaction is the reaction time during which the subject's attention is directed to the stimulus rather than the response.

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk?

shearing force Explanation: A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information." Explanation: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?

"Any information that can identify a person is considered a breach of client privacy." Explanation: Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. Discussion of clinical practice can be helpful for learning purposes or seeking advice on care. No care should be discussed, even privately, with friends and family without first obtaining the client's permission.

The school nurse is preparing a teaching plan for young school-aged children on ways to maintain eye health and prevent eye damage. What information would the nurse include in the plan? Select all that apply.

"Do not rub your eyes." "Do not look directly at the sun on sunny, bright days." "If you have difficulty seeing objects, report this to your parents or teacher." Explanation: Instructions to include in a teaching plan about maintaining eye health and preventing eye damage include do not rub the eyes, avoid damage from ultraviolet rays, and know the danger signals that may indicate serious eye problems. Thus, the nurse would instruct the children not to look directly at the sun on sunny, bright days. The nurse would teach the children to notify an adult if the child has difficulty seeing objects. The nurse would include information about not reading in poor light. This will cause eyestrain. The nurse would include information about cleaning the eyes with clean cloths to avoid injury or infection of the eyes.

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?

"Have you tried nasal strips?" Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring. Other choices are incorrect.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." Explanation: SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing." Explanation: Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the physician not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply.

"I will write, print, or type information legibly." "I will use only agency-approved abbreviations." "I will draw a straight line through any blank space." Explanation: Writing, printing, or typing information legibly will prevent the entry from losing its value for exchanging information if it is unreadable. Using only agency-approved abbreviations promotes consistency in interpretation. Drawing a straight line through any blank space will reduce the possibilities that someone else will add information to the current documentation. Staying logged in on the computer until the end of the shift is incorrect, as it is a security risk. Best practice is that the nurse logs off each time the nurse has completed an entry. Elaborating on the details on the entry in the clients' records is not in keeping with best practice. The entry should be brief but complete.

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?

"It combines nursing science with information management and analytical sciences." Explanation: The ANA defines nursing informatics (NI) as "the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice." It is more than just working with computers or the electronic health record (although this is the core of informatics practice). Client education can be one component of a clinical information system with which nursing informatics may be involved.

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips?

"Nasal strips may reduce or eliminate snoring." Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring. The other responses are inappropriate.

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

"Necrotic tissue is devitalized tissue that must be removed to promote healing." Explanation: The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records." Explanation: The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses.

The student is explaining the factors affecting sensory stimulation to his professor. The professor knows that which of the student's statements is most accurate?

"Religious norms within a culture influence the amount of sensory stimulation a person seeks." Explanation: Ethnic norms, religious norms, income group norms, and the norms of subgroups within a culture all influence the amount of sensory stimulation a person seeks and perceives as meaningful. The amount of stimuli different people consider optimal appears to vary considerably. Sensory functioning tends to decline progressively throughout adulthood. Narcotics and sedatives decrease awareness of sensory stimuli.

The nursing student is studying the reticular activating system (RAS). Which statement indicates to the professor that the student has mastered the information?

"The RAS serves to monitor and regulate incoming sensory stimuli." Explanation: The RAS serves to monitor and to regulate incoming sensory stimuli. To receive stimuli and respond appropriately, the brain must be alert or aroused. The RAS, a poorly defined network, extends from the hypothalamus to the medulla. Nerve impulses from all the sensory tracts reach the RAS, which then selectively allows certain impulses to reach the cerebral cortex and to be perceived.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

"The caregiver will need to place the oxygen tank back into the secure carrier." Explanation: Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.

The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?

"This is a gauge used to regulate the amount of oxygen that a client receives." Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes.

Which is the proper way to document midnight in a client's record?

0000 Explanation: 0000 is the military time for midnight and is correct. The other military times are incorrect since 2401 is 1 minute past midnight, 1200 is noon, and 1201 is 1 minute past noon.

Which situation demonstrates sensory adaptation?

A client has learned to sleep through the frequent beeping of the intravenous pump. Explanation: Adaptation occurs when the body adapts to constant stimuli, such as the continuous beeping of a hospital device. Adaptation is not the same as compensation. Compensation is when the client learns sign language for the hearing loss, and uses large print books for visual changes. A client believes their hearing has become more acute since the loss of his vision is an assessment of a personal change and not a nursing assessment.

The wound care nurse is performing skin assessments for clients at risk for the development of skin alterations. Which clients does the nurse identify as at greatest risk for skin alterations? Select all that apply.

A client with morbid obesity A client with reports of excessive perspiration A client that has a low BMI Explanation: Very thin (low BMI) and very obese people tend to be more susceptible to skin irritation and injury. Excessive perspiration, often associated with being ill, predisposes the skin to breakdown, especially in skin folds. Jaundice, a condition caused by excessive bile pigments in the skin, results in a yellowish skin color. The skin is often itchy and dry, and clients with jaundice are more likely to scratch their skin and cause an open lesion with the potential for infection.

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?

Ambu bag Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.

An informatics nurse is assisting with the development of a new clinical information system that will be implemented in the facility. As part of the process, the team is evaluating the purpose of the system and the technological options available. The team is in which phase of the system development lifecycle?

Analyze and plan Explanation: During the analyze and plan phase, questions related to the purpose, the problem being solved, and the technological options available are addressed. Design addresses the display characteristics, whether the design supports or improves workflow, and recommendations for design based on evidence. The test phase involves how the components of the system work. The train phase involves teaching of the end users.

When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?

Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation. Explanation: The skin barrier should be placed at least 1 in (2.5 cm) away from the area of irritation and should be placed on both sides of the wound. Skin barrier should not be placed over the area of irritation; it should only be placed on skin that is intact. The skin barrier should be applied to both sides of the wound as the Montgomery straps are applied to both sides of the wound on the intact skin surrounding the wound and 1 in (2.5 cm) away from any irritated or nonintact skin.

The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed?

Apply steady, firm pressure on the puncture site for 5 to 15 minutes. Explanation: Because the artery has been punctured, there is an increased risk for puncture site bleeding compared to venous blood draws. The nurse should apply steady, firm pressure on the puncture site for 5 to 15 minutes or until bleeding has completely stopped. An adhesive bandage should not be placed before bleeding is stopped. The blood specimen should be properly labeled; however, the priority for the nurse would be to ensure bleeding from the puncture site has stopped. Pressure should be applied prior to any extremity elevation.

A nurse is working with a preceptor after transferring to a unit where many of the clients are confused or unconscious. The preceptor determines that teaching is necessary when this nurse interacts with an unconscious client in which manner?

Approaches the bed, takes the client's hand, and introduces herself. Explanation: The nurse should speak before touching the client. It is unknown if unconscious clients can hear and understand, but the nurse should assume they can. Explaining the steps of a procedure and calling the client by name are appropriate as is turning off background noise while speaking to the client.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate?

Ask the client if information can be given to the parent. Explanation: No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

Ask the client what factors contribute to nonadherence. Explanation: The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?

Bronchitis Explanation: Bronchitis refers to a condition in which the airways become inflammed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member Explanation: Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

A client in a long-term care facility cannot control the direction of thought content, has a decreased attention span, and cannot concentrate. Which effect of sensory deprivation might the client be experiencing?

Cognitive response Explanation: Cognitive responses involve the client's inability to control the direction of thought content. Typically, attention span and ability to concentrate are decreased. Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, and body position, coordination, and equilibrium. Emotional responses typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. A physical response does not relate to thought processes.

The nurse is caring for a client who suffered a stroke 3 days ago and is assessing the client's state of arousal. Which is the best way to determine the client's level of being alert and responding appropriately to the environment?

Collecting mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills. Explanation: Sensoristasis refers to a person's optimum state of arousal through stimulation. When stimulation is constant, adaptation occurs. To determine the client's level of alertness the nurse should collect mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills. Collecting only portions of the senses such as just vision and hearing is not a thorough assessment. Likewise, determining only loss of sensory skills is not thorough enough to address sensoristasis.

An informatics nurse specialist is collecting data from the clinical information system about the demographics of individuals diagnosed with heart failure admitted to the facility over the past five years. The nurse specialist is preparing a presentation to the facility's executive board. To promote understanding of this complex information, the nurse specialist prepares the data results using a pie chart and a bar graph. The nurse specialist is using which area of analytics?

Data visualization Explanation: Data visualization is the presentation of data in a pictorial or graphical format. It enables decision makers to see analytics presented visually, so they can grasp difficult concepts or identify new patterns. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. Big Data comprises the accumulation of health care-related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom. Data mining refers to the process of sorting through large amounts of data to identify patterns and solve problems.

An informatics nurse specialist is working as part of a team that will be developing and implementing a new client assessment tool. During which phase of the system development lifecycle would the team be integrating information about workflow patterns, standard terminology, and recommendations for screen layout from supportive research?

Design and build Explanation: Mapping out workflow patterns, using standard terminology, and integrating evidence-based research findings for screen layouts would be accomplished during the design and build phase of the system development lifecycle. During the analyze and plan phase, the team would determine the purpose of the technology and the problem to be solved to establish the need. Testing is done once the technology is designed and built. Training of the end-users occurs after the system is tested but before it is implemented.

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me!" Which nursing diagnosis is appropriate for this client?

Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me." Explanation: The correctly written nursing diagnosis is Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me." Since the nursing diagnosis is not a "risk for" diagnosis, it must have a "related to" and "as evidenced by" statement.

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard. Explanation: Documenting all personnel who have accessed a client's record, placing light boxes for examining X-rays with the client's name in private areas, and having conversations about clients take place in private where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Orienting computer screens toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of patient confidentiality.

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

Document this expected assessment finding. Explanation: A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. Which suggestion could the nurse make to improve the client's respiratory function?

Drink liberal amounts of fluids. Explanation: The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. The nurse should advise older adults to receive annual influenza immunizations and a pneumonia immunization after 65 years of age or earlier if there is a history of chronic illness.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein. Explanation: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.

Which skin disorder is associated with asthma?

Eczema Explanation: The client with asthma often recalls childhood allergies and eczema.

An informatics nurse is evaluating a new clinical information system for usability. The nurse notes that the system requires the user to complete a maximum of 3 steps to complete a task. The system also provides shortcuts to frequent users of the system. The nurse would determine that which concept of usability is being addressed?

Efficient interactions Explanation: Efficient interactions is demonstrated by actions that facilitate efficient user interactions. An example is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users. Consistency involves the ability of the users to apply prior experience to a new system so that the lower the learning curve, the more effective their usage, and the fewer their errors. Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user.

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

Every 48 to 72 hours Explanation: In a non-infected wound, the negative pressure dressing should be changed every 48 to 72 hours. The negative pressure wound therapy should not be disturbed or interrupted more often than that unless the wound is infected. Infected wounds may require dressing changes every 12 to 24 hours.

An informatics nurse is participating in an online continuing education course about nursing informatics. The nurse demonstrates successful comprehension of the course by identifying which individual as being considered the first informatics nurse?

Florence Nightingale Explanation: Many have documented that the first informatics nurse was Florence Nightingale, who compiled and processed data to improve sanitation conditions in military hospitals during the Crimean War in the 1850s. Orem, Peplau, and Henderson are nursing theorists.

Assessment of a client reveals that the client is experiencing sensory deprivation. Which finding would the nurse identify as a perceptual response to this situation? Select all that apply.

Hallucinations Daydreaming Explanation: Sensory deprivation can lead to perceptual, cognitive, and emotional disturbances. Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, and body position, coordination, and equilibrium. These responses can range from mild distortions such as daydreams, to gross distortions such as hallucinations. Cognitive responses involve the client's inability to control the direction of thought content. Typically, attention span and ability to concentrate are decreased. The client may demonstrate difficulty with memory, problem solving, and task performance. Emotional responses typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. Rapid mood changes also may occur.

Older adult clients easily become confused when admitted to the hospital. The nurse understands that there are various reasons for this. Which reason further supports this phenomenon?

Hospital procedures and its environment may trigger sensory overstimulation. Explanation: A primary nursing concern is to prevent symptoms of sensory overload for clients. Risk for sensory overload greatly increases when unfamiliar procedures are taking place and the business of the health care facility. The client is not affected by the different hospital personnel but the overabundance of personnel. It is not true to assume that older clients respond poorly to instruction. Confusion for the older adult in the health care setting is related to sensory overload rather than infection.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia Explanation: Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.

An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?

Identify clients at risk for infection Explanation: Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, organizations often use this information to identify clients who may be at risk for problems. This area of health care analytics is not involved with determining client satisfaction, evaluating client care, or correlating the client's diagnosis with interventions.

A facility is considering the addition of an alert system to the current electronic documentation system. The goal is to identify clients at risk for post-operative complications based on client data. A team consisting of an informatics nurse specialist, information technology experts, and nurses work on this. The team is currently in the "analyze and plan" phase of the system development lifecycle. Which activity would the team be involved with at this time? Select all that apply.

Identifying the specific purpose for this system Collecting data to determine the seriousness of postoperative complications Evaluating how the system might affect the current electronic documentation system Assessing how the system can be incorporated into the nurses' current workflow patterns Explanation: Before considering the employment of any type of new technology or an update to a system already in place, analysis and planning must take place. Activities that may be involved include: determining the purpose of the new technology or change to the current technology; identifying the problem to be solved; evaluating the data available to support how serious the problem is; evaluating how the system's use will be incorporated into the current workflow of the nurse; and how it will affect the overall usability and experience with the EHR.

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory Explanation: Impaired memory is a state in which an individual experiences the inability to remember or recall bits of information or behavioral skills. Disturbed sensory perception is a state in which the individual experiences a change in the amount, pattern, or interpretation of incoming stimuli. Acute confusion is the abrupt onset of a cluster of global, transient changes, and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycle. Chronic confusion is an irreversible, long-standing, or progressive deterioration of intellect and personality, characterized by decreased ability to interpret environmental stimuli or decreased capacity for intellectual thought.

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test?

Implement measures to prevent complications after arterial puncture. Explanation: During the arterial blood gas test, the nurse should implement measures to prevent complications after the arterial puncture. The nurse would not be involved in measuring the partial pressure of oxygen dissolved in plasma or the percentage of hemoglobin saturated with oxygen. Intensive care nurses commonly obtain arterial blood gases.

A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply.

Improvement in health care quality Greater client engagement Reduction in privacy breaches of client information Explanation: Meaningful use would be reflected by improved quality, safety, efficiency, and reduced health disparities; engagement of clients and family; improved care coordination and population and public health; and maintenance of privacy and security of client health information.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident report Explanation: An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed. Explanation: Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?

Inquire about factors that contribute to non-adherence. Explanation: The nurse must first assess the reasons that contribute to non-adherence; interventions cannot be determined without a thorough assessment. Other interventions take place after assessment.

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough. Explanation: The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.

The client who has been recently diagnosed with a stroke is observed to have changes in sensory reception. Which statement justifies the change in behavior?

Ischemia in certain parts of the brain interferes with nerve functions. Explanation: Altered sensory reception occurs in such conditions as spinal cord injury, brain damage, changes in receptor organs, sleep deprivation, and chronic illness. The person does not receive adequate sensory input because of an interference with the nervous system's ability to receive and process stimuli and in this case a loss of perfusion and ischemia as a result of a stroke. The decrease of blood flow inhibits perfusion and not intracellular hormones. The medications used to treat clots do not cause confusion but the stroke impairment does. The client may be unfamiliar with the setting but this is not the pathophysiology of what occurs with a stroke.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen. Explanation: The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice?

It is appropriate to use clean technique during this procedure. Explanation: Chronic wounds and pressure injuries may be treated using clean technique; aseptic technique is not always necessary. Disinfectants are not normally applied to wound beds except in exceptional circumstances.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings. Explanation: Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?

It regulates the amount of oxygen received. Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?

Maintain the client's oxygenation and alert the health care provider immediately. Explanation: If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

A client is prescribed a corticosteroid for the treatment of asthma after having an asthma attack. What education should the nurse provide to the client regarding the administration of this medication?

Monitor blood pressure and blood sugar. Explanation: Blood pressure and blood glucose levels may rise while taking corticosteroids and levels should be measured. The sodium intake should be decreased and not increased while taking corticosteroids. This medication will not cause drowsiness and may have the effect of sleeplessness. The best time to weigh yourself is first thing in the morning when rising.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

Monitor the amount of oxygen saturation in the blood. Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls?

Monitor the client frequently. Explanation: Individualized nurse-client interaction promotes sensory health function. Clients at risk for sensory deprivation may need frequent interaction initiated by the nurse, whereas others may not. In any case, provide appropriate stimuli, such as addressing the client by name, introducing and reintroducing yourself as necessary, explaining all activities, and when leaving, acknowledging when you will return. Family may not be available to assist with client at all times. With a sensory deprivation, the client may not understand the nurse's teaching about fall prevention. Restraints should be used if other less restrictive measures have been exhausted.

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

Obscuring identifiable names of clients and private information about clients on clipboards Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public Keeping record of people who have access to clients' records Explanation: Obscuring identifiable names of clients and private information about clients on clipboards; placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public; and keeping record of people who have access to clients' records are required under the Health Insurance Portability and Accountability Act (HIPAA), which is legislation that attempts to limit casual access to the identity of clients. Posting information linking a client with diagnosis, treatment, and procedure on whiteboards and making the names of clients on charts visible to the public are violations of HIPAA, as these activities allow casual access to the identity of clients.

An informatics nurse specialist is conducting an orientation for the staff of a primary care provider's office about a new web-based tool that they will be implementing. The goal of the tool is to promote patient engagement. The informatics nurse specialist is most likely orienting the staff to which system?

Patient portal Explanation: A primary patient engagement tool is the patient portal, a web-based tool that can be securely accessed and provides several functions to increase engagement. Telehealth is defined as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Telemedicine involves the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes.

An informatics nurse specialist is preparing a presentation for a local community group about advances in technology in health care. Part of the presentation will focus on technological advances to promote greater client participation in managing health. Which component would the nurse likely describe as playing a major role?

Patient portal Explanation: Although the electronic health record and clinical information systems are important technological advances in health care, engaging clients in their care and working together to improve health with supportive technology is an area that continues to advance. A primary client engagement tool is the patient portal. This web-based tool can be securely accessed and provides several functions to increase engagement. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. It does not involve client engagement.

The nurse is caring for Nancy, a 45-year-old client with diabetes mellitus. She has severe neuropathy and consequently has little or no feeling in her feet and lower legs. The nurse includes which nursing interventions in the care plan related to this lack of tactile sensation? Select all that apply.

Perform frequent, thorough skin assessments. Assess for shoe type and correct fit. Educate client to never go barefoot. Protect skin from temperature extremes. Explanation: For a client with a decreased sense of touch, do the following: protect the client's skin from temperature extremes; assess the extremities for breaks in the skin, blisters, drainage, or open wounds; and ensure the client is ambulating with assistive devices. Clients with diabetic neuropathy should wear shoes with a wide toe box, should not go barefoot, and should wear clean, white cotton socks.

A nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress?

Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration Explanation: If a nurse is conducting a health history interview for a client diagnosed with chronic bronchitis when respiratory distress occurs, the nurse first places the client in a comfortable position, ensures a patent airway, and starts oxygen if prescribed. After ensuring an open airway, the next step is quickly assessing the respiratory rate and quality and then getting assistance in case the client's respiratory status starts to deteriorate. Speaking slowly and calmly to relax the client is valuable but does not help assess the client's respiratory distress or prepare to manage it. The condition may require further intervention so preparation is needed.

A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer?

Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. Explanation: A nebulizer is used to administer medications in the form of an inhaled mist. The nurse will instruct the client to place the mouthpiece in the mouth, keep the lips firm around the mouthpiece so that all of the medicine goes into the lungs, and continue until the mist stops. Any other option allows for the medication to be lost, rather than inhaled into the lungs.

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs Explanation: Pressure injuries are caused by unrelieved compression of the skin that results in damage to underlying tissues. Pressure points in bed vary depending on the size and shape of client and the position. Pressure points while sitting in a chair or wheelchair also vary depending of the style, shape, and construction of the chair or wheelchair, the clients position in the chair, and the size and shape of the client. Any boney prominence or areas under a large amount of pressure against a hard or semihard surface can create a pressure injury. To protect clients at risk for pressure injury, the nurse implements a 2-hour turn schedule, uses a pressure redistribution support surface, keeps pressure points from pressing on the bed or chair by using positioning devices or pillows, keeps boney prominences from rubbing on each other, minimizes exposure of skin to incontinence, perspiration, or wound drainage, and provides adequate calories and nutrients. A pillow placed between the lower legs in side-lying position will prevent ankle to ankle pressure, but not ankle to mattress pressure. Placing a pillow under the knees while positioned supine will increase pressure on the heels. While using a wheelchair, it is best to have the client wear well-fitted shoes and position the feet on the footplate and remove the heel rest or heel loop.

Which principle should guide the nurse's documentation of entries on the client's health care record?

Precise measurements should be used rather than approximations. Explanation: Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians and photographs can constitute documentation. Handwritten entries should be struck through with a single line and initialed, not covered with correcting fluid or erased.

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Explanation: Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients' problems among caregivers and having numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care are examples of source-oriented recording.

The older adult client, who lives alone, has been admitted to the intensive care unit (ICU) following a stroke. She is now agitated and complaining about the noise. What will the nurse add to her care plan?

Provide a consistent, predictable pattern of stimulation. Explanation: In some clients, especially those coming from a quiet environment with unvarying stimuli, the experience of being hospitalized quickly results in sensory overload. One nursing action to decrease excessive stimulation is to provide a consistent, predictable pattern of stimulation to help the client develop a sense of control over the environment. The other options are nursing interventions used for sensory deprivation, as they increase stimulation

The following are steps on how to remove the client's contact lenses. After the nurse washes her hands, which step should be done next?

Pull the client's upper and lower lid apart and pull tautly toward the lateral side. Explanation: A nurse should know how to remove contact lenses in a client. The following are the steps. 1. Wash hands > 2. Position client comfortably in a sitting position, if possible. > 3. Pull the client's upper and lower lid apart and pull tautly toward the lateral side. > 4. Ask the client to blink, and the lens should pop out into your hand. > 5. An alternative method for removing hard contact lenses is the use of a lens suction cup. This is particularly useful for a client who cannot consciously assist with the removal. After removal, the lenses should be placed in contact lens solution or normal saline to protect the lenses from drying out. The lens should not be grasped with the thumb and index finger.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Pulmonary function tests Explanation: Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

The nurse working in the intensive care unit is preparing to admit a client from the emergency department who had a stroke located in the medulla. What equipment should the nurse have present in the room upon the client's arrival into the unit? Select all that apply.

Pulse oximeter Ventilator Explanation: The medulla houses the respiratory center, which regulates respirations. If damaged, the client will need monitoring of oxygenation (pulse oximeter) and a mechanism for breathing, getting oxygen, and clearing secretions from the airway (endotracheal tube). There is no indication that the client's lungs have collapsed, so a chest drainage system is not needed. A communication board would be used if the client could not be understood. It is important to record temperature, but the most important items are pulse oximeter and endotracheal tube.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Explanation: If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and she believes she is in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time. Explanation: It is appropriate to reorient clients who are confused. Doing so in an effective and empathic manner requires the astute implementation of nursing skills. Engaging more deeply with the client's incorrect responses does not reorient her. Attempting to reorient the client in a subtle and indirect manner is not likely to be effective. Documenting the client's response is necessary, but this should be followed up by reorientation.

The nurse is preparing to reposition a confused client from a supine position to a side-lying position. The nurse has asked the client to shift her weight accordingly, but the client has not responded to the nurse's request. How should the nurse respond?

Rephrase the direction in different terms. Explanation: Rephrasing an instruction in simple terms may enhance a confused client's understanding. This is preferable to proceeding in spite of the client. Asking for help from a colleague and asking the client if she feels confused are not likely to enhance communication with the client. If the nurse repositions the client without involving the confused client, it may cause more confusion and anger of the client toward the nurse.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting Explanation: Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

Which method will the nurse use to instruct a parent to help the newborn develop body placement and movement?

Rock and cuddle the newborn. Explanation: Appropriate stimulation includes soothing, holding, rocking and changes of position. Having the newborn in the crib for several hours or swinging the newborn in a jumper can cause under/overstimulation. Having the infant sleep between two bumpers may put the newborn at risk for suffocation.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing?

Sensory deficits Explanation: Sensory deficits in vision and hearing interfere with one's ability to interact with other people and with the environment.

A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted?

The graduate nurse auscultates breath sounds as the client breathes through the nose. Explanation: Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximeter are included in the respiratory assessment.

The nurse is discussing traditional cultural beliefs relating to skin care and healing with a group of nursing students. Which remark by a participant indicates the need for further instruction?

The nurse is discussing traditional cultural beliefs relating to skin care and healing with a group of nursing students. Which remark by a participant indicates the need for further instruction?

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. Explanation: Sometimes the physician orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site.

Which is not a purpose of the client care record?

To serve as a contract with the client Exaplanation: Client care records are legal documents, communication tools, and assessment tools. They are used for care planning, quality assurance, reimbursement, research, and education. They in no manner reflect a contract between health care staff and the client. The only exception to this is at the point of admission when the client (or responsible party) signs an acknowledgement of expenses about to be incurred as health care insurance information is obtained.

The nurse is testing the client's neurological status. Which action will the nurse take to assess the client's sense of touch?

Touch the temple with a cotton ball so the client can identify where being touched and if the touch is soft or sharp Explanation: To test the sense of touch the nurse should touch the temple with a cotton ball and ask the client to identify where the nurse is touching and if the touch is soft or sharp. Pricking the client's skin with a lancet or holding a hot tuning fork may be dangerous. Bending the client's fingers will not provide reliable information about the sensation of touch.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?

Translators may need additional explanations of medical terms. Explanation: When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True Explanation: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?

Usability Explanation: The nurses' statement reflects usability. Electronic health records and order-entry systems are complex. Sometimes the way screens are formatted can be confusing, making it a real challenge to perform nursing tasks in a way that makes sense. Interoperability refers to the ability to share data across health care systems. Optimization refers to strategies to improve processes, maximize effective use, reduce errors, reduce costs, eliminate workflow inefficiencies, improve clinical decision support, and improve end-user skills and satisfaction with the system. Security refers to the ability to keep information private and confidential.

An informatics nurse specialist is part of a team working to design a new electronic documentation system for the facility. To ensure maximum usability, which information would the team need to consider? Select all that apply.

Use of color for meaning, not attractiveness Use of standard terminology to quantify nursing care Explanation: When designing a system, usability is important. To promote usability, the system should use color judiciously to convey meaning to the user; employ the use of standard terminology to allow for quantification of nursing care; avoid putting too much information on a screen because doing so can lead to increased visual search times and user errors; keeping screen changes and visual interruptions to a minimum.

An informatics nurse specialist is conducting an in-service education program for a group of staff nurses. The topic is ensuring electronic client data is secure and private. The specialist determines that the teaching was successful when the group identifies which aspect as essential to ensuring the security of electronic data when using clinical systems?

Use of strong passwords Explanation: Nurses are responsible for minimizing the risk of harm to clients and providers through both system effectiveness and individual performance. Ensuring secure and appropriate access to clinical systems starts with good management of passwords, including the use of strong passwords. Interoperability and intuitive design are not associated components to ensure secure data. Testing is an important component in the system development lifecycle (SDLC).

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular Explanation: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

Which way can the nurse decrease the sensory deprivation that the client in isolation experiences?

Visit the client often to develop trust. Explanation: To lessen the feelings of isolation the nurse should visit the client often and let him or her know when to expect another visit to help the client overcome a feeling of isolation. Providing a calendar and a clock to assist in keeping track of time helps keep the client in touch with activities in the environment. Also, the nurse encourages the client to provide self-stimulation, such as singing, reading, and talking into a recorder and playing it back. Self-care activities also are forms of self-stimulation. The nurse provides various types of stimulation to encourage maximum use of the client's available senses. This action would include self-care activities that can stimulate sensory perception and awareness. Visitors should be kept to a minimum to prevent the spread of infection.

A client with a history of pressure injuries is discussing nutrition with the nurse. The client correctly indicates plans to include which vitamin in the diet to promote wound healing? Select all that apply.

Vitamin B3 (niacin) Vitamin B6 (pyridoxine) Explanation: Adequate intake of vitamins A, B6, C, K, niacin, and riboflavin is important to prevent abnormal skin changes.

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting Explanation: PIE charting includes the problem, intervention, and evaluation. The only entry that follows PIE charting is vomiting 250 mL undigested food (problem), antiemetic given (intervention), no further vomiting (evaluation).

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?

Warm the client's hands and try again. Explanation: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

Wheezing Explanation: The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm. Explanation:When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

a child who has pneumonia Explanation: An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing care Explanation: Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

The is caring for a client that states, "I am hearing voices in my head" . What does the nurse identify is occuring with the client?

a hallucination. Explanation: Hallucinations, sensory impressions that are based on internal stimulations, have no basis in reality. Hearing voices when no one is there is a typical auditory hallucination. Delusions are fixed beliefs, not based in reality. Illusions are misperceptions of actual stimuli.

A nurse is admitting a 6-year old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion. Explanation: Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

Which client is at greatest risk of sensory overload?

an 88-year-old on a ventilator in an intensive care unit Explanation: Intensive care units, mechanical ventilators, lengthy verbal explanations prior to procedures, and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload. Private rooms, mobility restraints (such as traction or bed rest), isolation, and few visitors are all risk factors for sensory deprivation.

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders Explanation: Any identifying information regarding the client's demographics such as name, age, gender, diagnosis, and so on should be communicated to the oncoming nurse caring for the client. Any current orders or orders that have not been completed during the shift should be communicated as well. The oncoming nurse should be informed of any occurrences with the client that have been out of the norm and what actions, if any, were taken. Information about what the client watched for entertainment is not of relevance and should be eliminated from the report, as well as what time the nurse will be working next.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

atelectasis. Explanation: Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure. Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply.

covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position using sterile technique Explanation: Evisceration of a wound is a medical emergency. The client should be placed in a low Fowler position and, with the use of sterile technique, the eviscerated structures should be covered with normal saline-moistened gauze. The surgeon should also be notified. The nurse should never reinsert protruding structures or apply a pressure dressing. This could cause the tissue to be injured. The wound should not be packed with iodoform gauze. The client will have surgery to replace the eviscerated structures.

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:

croup. Explanation: Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as:

delirium. Explanation: Delirium involves disorientation, restlessness, confusion, hallucinations, agitation, and alternating with other conscious states, whereas dementia is associated with difficulties with spatial orientation, memory, language and changes in personality. Somnolence refers to a state of extreme drowsiness, but the client will respond normally to stimuli. Locked-in syndrome refers to a state of full consciousness where sleep-wake cycles are present, and where quadriplegic, auditory and visual function, and emotion are preserved.

The nurse is working on a neurological unit and a physician asks the nurse to perform a sensory experience assessment for a client. The nurse thinks about what things may place a person at risk for disturbed sensory perception and comes up with which of the following? Select all that apply.

diminished senses related to advanced age neuropathy related to diabetes mellitus medications that alter certain senses Explanation: Aging is often accompanied by diminished senses. Diseases can diminish senses. Diabetes-related neuropathies can result in a loss of sensation in the limbs, rendering the client with diabetes unable to feel hot objects such as bath water, which can result in burns. Certain drugs affect taste. Wearing corrective devices, such as eyeglasses and hearing aids, does not put anyone at risk for disturbed sensory perception.

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent Explanation: A face tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. A simple mask or nasal cannula would irritate the facial skin. The client does not have a tracheostomy.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

hemoglobin level. Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?

hemostasis phase Explanation: Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and release growth factors. The proliferation phase is the regenerative phase, in which granulation tissue is formed. The maturation phase involves collagen remodeling.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data. Explanation: A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document. Explanation: The client record serves as a legal document of the client's health status and care received. An assessment tool may be a formal document that is included as part of the client's record. A Kardex is typically an erasable, temporary document that would be shredded when no longer needed for the client's care. Incident reports are internal documents that are not a part of the client's record, and therefore not a legal document regarding their health care.

The nurse is caring for a client with sensory perception deficits. Which sensory aids can the nurse use for this client to adjust to these deficits? Select all that apply.

literature with large print speaking slowly fresh food served for meals turning and repositioning sips of water between foods Explanation: All of these sensory aids can help promote optimal function of the impaired sense and other available senses.

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?

nasal cannula Explanation: A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

progress notes Explanation: In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

A client who has awakened from a coma after a car accident and states, I knew about a news story reported during the time I was in the coma." What does the nurse identify is occuring with the client?

reticular activating system's stimulation. Explanation: Destruction of the reticular activating system produces coma and an electroencephalograph pattern consistent with sleep. When the nervous system is oriented to a stimulus and receptive toward it, the neurons of the RAS arouse the brain, facilitating information reception (Widmaier, Raff, & Strang, 2008). The RAS is highly selective.

A nurse explains to a client what he will typically see, hear, and feel during his scheduled surgery. The nurse is engaged in:

sensation information. Explanation: The nurse is implementing procedure preparation to prevent overstimulation of the client before the surgery. More specifically, the nurse is using sensation information which involves objectively and specifically describing to the client, in serial order, what he typically will see, hear, smell, taste, or feel (tactile) in a particular situation (rare or atypical events are not to be included). Outcome identification is the establishment of goals and outcome criteria to achieve optimal sensory function. Dysfunction identification is an assessment method used to identify actual sensory loss. Stimulation reduction is a nursing intervention for altered sensory perception function, which involves reducing the amount of stimulation provided to the client to promote sensory perception.