Nursing 101: Exam 1

A client with multiple sclerosis is being taught how to perform self-catheterization. As part of this teaching the nurse instructs the client to do which of the following? (Select all that apply.) A) Increase intake of fluids. B) Always use clean technique. C) Always use sterile technique. D) Use petroleum jelly to lubricate the catheter tip.

A and B Sterile technique is required for urinary catheter insertion in the hospital, but when catheterization is performed at home by the client only clean technique is required. The hospital is populated by a wide variety of microorganisms that could become pathogenic to the client. The client's own organisms do not generally cause disease. Intake of fluids is important to minimize the occurrence of urinary tract infections. Use of an oil-based lubricant is not recommended and may increase urinary tract infections. Water-based lubricants, which can be expelled from the urethra during voiding, should be used.

ealth care workers who have direct contact with individuals suspected of being contaminated with anthrax should do which of the following? (Choose all that apply.) A) Wear an isolation gown, gloves, and high-efficiency particle arrestor (HEPA) mask B) Prepare the client for transfer to the radiology department for chest radiography C) Instruct the client to wash the hands and exposed areas with soap and water D) Have the client remove clothing and place it in a sealed biohazard bag

A and D Anthrax is caused by a spore-forming, gram-positive bacillus. Humans become infected through skin contact, ingestion, and inhalation. The nurse should wear an isolation gown, gloves, and a high-efficiency particle arrestor (HEPA) mask. The client should remove potentially contaminated clothing for testing and decontamination. The client should remain in isolation until it is certain that the bacteria have been contained, not transferred to radiology. The client should shower thoroughly with soap and water, not just wash hands and exposed areas.

The nurse is obtaining a client's medication history. Which of the following medications may cause gastrointestinal bleeding? (Select all that apply.) A) Aspirin B) Cathartics C) Antidiarrheal opiate agents D) Nonsteroidal anti-inflammatory drugs (NSAIDs)

A and D Aspirin and NSAIDs may cause gastrointestinal bleeding. Antidiarrheal opiate agents slow the motility in the gastrointestinal tract, and cathartics increase motility.

Symptoms associated with anemia include which of the following? (Select all that apply.) A) Increased breathlessness B) Decreased breathlessness C) Increased activity tolerance D) Decreased activity tolerance

A and D Clients with anemia have fatigue, decreased activity tolerance, and increased breathlessness, as well as pallor (especially seen in the conjunctiva of the eye) and an increased heart rate.

The nurse instructs the client to avoid which of the following foods, which could give a false reading on the fecal occult blood test? (Select all that apply.) A) Fish B) Lasagna C) Cranberry juice D) Raw vegetables

A and D Fish and some raw vegetables can produce false-positive results if consumed during the collection of stool for occult blood testing. Although lasagna and cranberry juice are red, they do not irritate the gastrointestinal tract so that bleeding occurs. The fecal occult blood test measures blood in the stool and is unaffected by foods that are red.

The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS), the best position in which to place the baby after nursing is (select all that apply): A) Prone B) Supine C) Fowler's D) Side lying

A and D Research demonstrates that the occurrence of SIDS is reduced with these two positions. Placing the infant prone has been implicated as a cause of SIDS. Fowler's position is a semi-sitting position and has not been discussed in the prevention of SIDS.

A client is experiencing nausea and abdominal distention postoperatively. The nurse initiates the interventions listed below. Which of the interventions is an example of an independent intervention? (Select all that apply.) A) Provides frequent mouth care B) Maintains intravenous infusion at 100 ml/hr C) Administers prochlorperazine (Compazine) via rectal suppository D) Consults with the dietitian on initial foods to offer the client E) Controls aversive odors and unpleasant visual stimulation that trigger nausea

A and E Providing frequent mouth care and controlling aversive odors and unpleasant visual stimulation that trigger nausea are examples of independent intervention. The other options are dependent interventions.

The nurse delegates to an unlicensed assistant the task of removing the restraints from the client's wrists every ________ hours and reporting any abnormalities. A) 2 B) 4 C) 6 D) 8

A) 2 Removal of restraints and inspection of the contact area every 2 hours is a requirement of The Joint Commission. The time periods in the other options are too long. The client could experience a serious complication if restraints are not removed and the area under the restraints inspected frequently.

Depending on the client's age and physical condition, the room temperature should be maintained between: A) 20° and 23.3° C (68° and 74° F) B) 23.9° and 25° C (75° and 77° F) C) 25.6° and 26.7° C (78° and 80° F) D) 18.3° and 21.1° C (65° and 70° F)

A) 20° and 23.3° C (68° and 74° F) A comfortable room temperature should be maintained for the client, about 20° to 23.3° C (68° to 74° F), depending on the client's comfort

Cyanosis, the blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is: A) A late sign of hypoxia B) An early sign of hypoxia C) A sign of a non-life-threatening condition D) A reliable measure of oxygenation status

A) A late sign of hypoxia Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of cyanosis is not a reliable measure of oxygen status.

When a nurse is performing surgical hand hygiene, the nurse must keep the hands: A) Above the elbows B) Below the elbows C) At a 45-degree angle D) In a comfortable position

A) Above the elbows When surgical hand hygiene is performed, the hands should always be kept above the elbows so that the water runs from the hands to the elbows.

Just before friends visit, a client reports to the nurse that his pain level is 7 out of 10. The nurse returns to the room with the ordered analgesic and finds the client laughing and joking with the friends. The nurse decides to: A) Administer the analgesic immediately. B) Record the pain intensity as 2 out of 10. C) Make a note that the client's behaviors do not indicate pain. D) Withhold the analgesic until the client requests it again.

A) Administer the analgesic immediately. Pain is what the client says it is. There is no single way in which pain manifests itself. Clients may be temporarily distracted from their pain when friends are visiting. Clients in pain may not want their friends and family members to know how much pain they are experiencing. In addition, laughing with friends or family members may be a distraction that diverts attention from the pain. Pain rated at 7 out of 10 requires immediate treatment.

A student nurse is designing a health fair project aimed at reducing motor vehicle accidents. For which group of clients would this subject be most appropriate? A) Adolescents B) Older adults C) Middle-aged adults D) School-aged children

A) Adoescents The risk of motor vehicle accidents is higher among teen drivers than in any other age group.

As a member of the hospital's bioterrorism team, the nurse understands the importance of knowing how an organism is transmitted. Smallpox has the potential to spread quickly because it is transmitted via which route? A) Airborne B) Ingestion C) Absorption D) Blood-borne

A) Airborne Organisms with an airborne route of transmission can claim many victims and spread very quickly. Smallpox is not spread via blood. There is no such thing as an absorption or ingestion route of transmission.

A client is scheduled for an intravenous pyelogram (IVP). Before the test the most important assessment the nurse performs is asking about: A) Allergies to shellfish B) Previous experience with IVP C) Family history of a reaction to IVP D) Ability to remain still during the procedure

A) Allergies to shellfish The contrast medium often used for IVP contains iodine. If a client is allergic to shellfish, then an allergy to iodine is suggested. Thus, the client may need to receive a contrast medium that does not contain iodine in order to avoid an allergic reaction.

A client is admitted to the emergency department with a suspected cervical spine fracture at the C3 level. The nurse is most concerned about the client's ability to: A) Breathe B) Ambulate C) Maintain cardiac output D) Be oriented to person, place, and time

A) Breathe Spinal cord injury at the level of C5 or above often results in damage to the phrenic nerve, which innervates the diaphragm and permits breathing. Cardiac output is not usually affected by spinal cord injury; however, cardiac output may be reduced as a result of trauma and blood loss. It is too early to be concerned with ambulation. Life-threatening problems take priority. Level of consciousness is certainly an important consideration, because this client most likely sustained a head injury. However, this is not a certainty given the data provided.

2. A physician wrote the following order for an opioid-naïve client who has returned from the operating room after total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes which of the following actions? A) Calls the physician and questions the order B) Applies the patch on the third postoperative day C) Applies the patch as soon as the client reports pain D) Places the patch as close to the hip dressing as possible

A) Calls the physician and questions the order The nurse calls the physician and questions this order. Onset of pain relief can take 18 to 36 hours after a fentanyl patch is applied. Fentanyl patches are used for long-term management of severe pain, so this is not an appropriate order for this client, who needs immediate, short-term relief. The patch should not be applied until the order is clarified and confirmed by the physician after short-term relief is started.

A female client reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is: A) Cystitis B) Renal stone C) Hemorrhage D) Incontinence

A) Cystitis Cystitis is usually marked by urinary frequency and irritation. The cloudiness is usually indicative of bacterial presence. A renal stone presents with pain and hematuria. Hemorrhage and incontinence are not correct options for this presentation.

6. Which intervention is appropriate to include on a care plan for improving sleep in the older adult? A) Decrease fluids 2 to 4 hours before sleep. B) Exercise in the evening to increase fatigue. C) Allow the client to sleep as late as possible. D) Take a nap during the day to make up for lost sleep.

A) Decrease fluids 2 to 4 hours before sleep. By decreasing fluids 2 to 4 hours before sleep, it is less likely that the client will awaken because of a need to urinate. Limiting naps during the day will help improve nighttime sleep. The client should sleep until the same time each morning. Exercising in the evening can make falling asleep more difficult.

The Healthy People 2010 initiative included recommendations to improve: A) Dental health B) Skin care in the elderly C) Medication management in the elderly D) The American diet, by adding more carbohydrates

A) Dental Health The Healthy People 2010 initiative (see Chapter 6) includes recommendations to improve the dental health of the population of the United States. The goals for oral health are to decrease tooth loss caused by tooth decay or periodontal disease for people aged 35 to 44; reduce the number of older adults who have lost their natural teeth; reduce the prevalence of gingivitis; and reduce destructive periodontal disease among individuals aged 35 to 44.

To facilitate communication with an older adult who is hard of hearing the nurse should: A) Face the client and maintain eye contact. B) Use lengthy explanations to ensure that the message is made clear. C) Cover several topics at one time to be most efficient in communication. D) Help the client by anticipating what he or she is going to say and finishing the client's sentences for him or her.

A) Face the client and maintain eye contact. The nurse should get the client's attention before speaking and face the client so the client can see the nurse's mouth. The nurse should speak slowly and clearly while maintaining eye contact. Words should be supplemented with visual gestures. The nurse should suppress the desire to finish the client's sentences. The nurse should allow the client to make errors. Short sentences with simple words should be used. The nurse should stick to one topic at a time.

The nurse is sure to implement strategies to reduce noise on the unit particularly on the ______ night of admission, when the client is especially sensitive to hospital noises. A) First B) Second C) Third D) Fourth

A) First The client is most sensitive to noise in the hospital setting on the first night because everything is new. This represents sensory overload, which interferes with sleep and decreases rapid eye movement (REM) as well as total sleep time. The other options are incorrect.

The nurse says to the client, "We've talked a lot about your medications, but let's look more closely at the trouble you're having in taking them on time." The nurse is using the therapeutic technique of: A) Focusing B) Clarifying C) Paraphrasing D) Providing information

A) Focusing Focusing is used to center attention on key concepts or elements in a message. Clarifying gives the client a chance to be more specific or provide more information. Paraphrasing means restating another's message briefly in one's own words. The nurse is not providing information here.

The nurse says to the client, "We've talked a lot about your surgery and the implications for you when you go home. Let's discuss some of the exercises you can do." This is an example of: A) Focusing B) Clarifying C) Summarizing D) Providing information

A) Focusing The nurse's statements depict the therapeutic communication technique of focusing. Focusing is used to center attention on key elements or concepts of a message. Focusing helps guide the direction of the conversation. Summarizing is a concise review of key aspects of an interaction. It brings closure to a conversation. Clarifying is used to check whether the listener's understanding is accurate. Instead of restating the message as in paraphrasing, the nurse asks the other person to rephrase the message, explain further, or give an example of what the person means. Providing relevant information tells other people what they need or want to know so that they can make decisions, experience less anxiety, and feel safe and secure.

When analgesics are ordered for a client with obstructive sleep apnea (OSA) following surgery, the nurse is most concerned about: A) Opioids B) Adjuvants C) Antidepressants D) Anticonvulsants E) Nonsteroidal antiinflammatory drugs (NSAIDs)

A) Opioids Clients with obstructive sleep apnea are particularly sensitive to opioids. Thus the risk of respiratory depression is increased. The nurse must recognize that clients with OSA should start out receiving very low doses of opioids. Options 2, 3, 4, and 5 have not been shown to increase the risk of respiratory depression in clients with OSA.

The most effective way to break the chain of infection is by: A) Practicing good hand hygiene B) Wearing gloves C) Placing clients in isolation D) Providing private rooms for clients

A) Practicing good hand hygiene Good hand hygiene is the most effective way to break the chain of infection. Wearing gloves can help in decreasing disease transmission, but clean hands are required for it to be truly effective. Placing clients in isolation is costly and often unnecessary, and clients can be psychologically harmed by isolation. Even providing private rooms for clients will not be effective if health care workers do not follow good hand hygiene practices.

Which of the following is an example of transpersonal communication? A) Prayer B) Negotiation C) Active listening D) Positive self-talk

A) Prayer Prayer is one form of transpersonal communication, in which interaction takes place in one's spiritual domain. Negotiation is often seen in the one-to-one interaction of interpersonal communication. Positive self-talk is a form of intrapersonal communication that can be used to improve one's self-esteem. Active listening is an important principle for effective communication in small groups.

The priority when providing oral hygiene to an unconscious client is to: A) Prevent aspiration. B) Prevent mouth odor. C) Prevent dental caries. D) Prevent mouth ulcerations.

A) Prevent aspiration. When providing oral hygiene to an unconscious client, the nurse should position the client appropriately and use suction to ensure that there is no risk of aspiration. Good oral hygiene is still necessary to prevent mouth odor, dental caries, and ulcerations.

The client reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that vivid dreaming occurs in which sleep phase? A) REM sleep B) Stage 1 NREM sleep C) Stage 4 NREM sleep D) Transition period from NREM to REM sleep

A) REM sleep The dreams of REM sleep are vivid and elaborate. The other answers are incorrect.

After performing a home assessment, a home care nurse might make which of the following safety recommendation to a family who will be caring for an older adult mother after discharge from the hospital? A) Set the water heater to a temperature that is not scalding. B) Change all the water faucets so that the mother can easily turn them on and off. C) Relocate the mother's bedroom upstairs so that she is not bothered by the activity of other family members. D) Place a small throw rug in the bathroom to absorb water dripping off the body so that the mother will not fall.

A) Set the water heater to a temperature that is not scalding. Lowering the water temperature in the hot water heater will prevent accidental burning of the mother's fragile skin during bathing.

In infectious diseases such as hepatitis B and C, a reservoir for pathogens is: A) The blood B) The urinary tract C) The respiratory tract D) The reproductive tract

A) The blood The blood is a reservoir for pathogens in hepatitis B and C. Neither organism can survive in the urinary, reproductive, or respiratory tract

A client undergoes ultrasonography of a kidney. The nurse providing postprocedure care remembers that: A) There are no special precautions that must be taken. B) Each urine specimen must be assessed for blood for 24 hours. C) All urine must be saved in a radiation-safe container for 12 hours. D) Contact with the client must be limited to 10 minutes each hour for 6 hours.

A) There are no special precautions that must be taken.

Maintaining a Foley catheter drainage bag in the dependent position prevents: A) Urinary reflux B) Urinary retention C) Reflex incontinence D) Urinary incontinence

A) Urinary reflux The Foley catheter drainage bag should be below the level of the bladder to prevent urinary reflux, which can lead to infection. The other conditions listed will not occur as a result of incorrect placement of a drainage bag.

14. Which of the following are myths regarding pain and pain treatment in older adults? (Select all that apply.) A) Pain is an inevitable part of aging. B) Older clients are unable to tolerate opioids. C) The pain center in older adults diminishes over time. D) Older adult clients are at greater risk for the development of conditions that are painful.

A, B and C Pain is not an inevitable part of aging. Older adult clients can tolerate opioids, although these drugs are best begun at a low dosage and the dosage gradually increased as needed. There is no one pain center in the brain, and the components of the nervous system associated with pain transmission do not diminish over time. It is true that as one ages, one is at greater risk for the development of painful conditions.

7. Which steps do you follow when you are asked to perform a procedure about which you are unfamiliar? Select all that apply. A) Seek necessary knowledge B) Reassess the client's condition C) Collect all equipment necessary D) Have an experienced nurse available to assist E) Consider all possible consequences of the procedure

A, B, C, D, and E Each of the five options is important in performing a new procedure. Be sure to seek all necessary knowledge, consider the possible consequences of the procedure, reassess the patient, collect the appropriate supplies, and ask a nurse experienced in the procedure to help out

A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data? (Select all that apply.) A) Pain intensity B) Location of pain C) Character of pain D) Radiation of pain E) Meaning of pain to the client F) Family history of myocardial infarctions

A, B, C, D, and E The nurse should gather the data the physician will need to determine whether the chest pain represents a myocardial infarction. Family history is important in comprehensive pain assessment; however, taking time to obtain this information is inappropriate in this critical situation.

A person's body image or sense of his or her physical appearance is which type of concept? A) Social B) Objective C) Subjective D) Developmental

A, B, C, and D A client's general appearance reflects the importance hygiene holds for that person. Body image is a person's concept of his or her body, including physical appearance, structure, and function. A person's body image includes all of the four concepts listed.

A client reports to the nurse that he wakes up early because of a need to urinate. The nurse recommends that the client avoid which of the following liquids after 8 PM? (Select all that apply.) A) Tea B) Cola C) Wine D) Coffee

A, B, C, and D All of the beverages listed are diuretics. In addition, alcohol inhibits the release of antidiuretic hormone, thus increasing water loss in urine.

Which of the following statements by the nurse would be nontherapeutic and tend to block communication? (Select all that apply.) A) "You look sad today." B) "Why are you so nervous?" C) "If I were you, I'd have the surgery." D) "I'm sure the test results will come out fine." E) "Tell me what it's like to live with dizziness."

A, B, C, and D Nontherapeutic statements hinder communication. False reassurances block communication and destroy trust. Asking for explanations can be interpreted as "testing" and can cause resentment, insecurity, and mistrust. Giving personal opinions takes the decision making away from the client.

A female client is having difficulty voiding after childbirth. The nurse implements which of the following interventions to promote voiding? (Select all that apply.) A) Turning the water tap on B) Ambulating the client to the bathroom C) Trickling warm water over the mons pubis D) Offering the client a large glass of cranberry juice E) Positioning the client on a fracture bedpan flat in bed

A, B, and C A woman urinates best in a sitting position on the toilet. Hearing water running may help the client relax to promote urination. Trickling warm water over the mons pubis may also signal the woman to relax the pelvic muscles and allow the sphincter to release of urine.

During the orientation phase of the helping relationship, the nurse might do which of the following? (Sellect all that apply) A) Discuss the cards and flowers in the room. B) Work together with the client to establish goals. C) Review the client's history to identify possible health concerns. D) Use therapeutic communication to manage the client's confusion.

A, B, and C In the orientation phase of the helping relationship, the nurse and client meet and get to know each other. The nurse reviews the history to identify possible health concerns before meeting the client. During the working phase, the nurse and client work together to solve problems and accomplish goals. Therapeutic communication would be used in all stages of the relationship.

What techniques encourage a client to tell his or her full story? (Select all that apply.) A) Active listening B) Back channeling C) Use of open-ended questions D) Use of closed-ended questions

A, B, and C Options 1, 2, and 3 encourage clients to tell their full stories. Closed-ended questions allow clients to answer with one or two words, which makes it more difficult to obtain all the information required for a full story. The other options give clients the opportunity to tell their stories and feel supported. Active listening helps them feel that they, and their stories, are important.

The nurse explains to a client with a new set of upper and lower dentures that the dentures should be cared for daily by doing which of the following? (Select all that apply.) A) Removing them at night B) Storing them in an enclosed labeled cup C) Covering them with water when they are not being worn D) Cleaning them with a weak bleach solution weekly

A, B, and C Removing dentures at night allows the gums to rest and prevents bacterial buildup. Covering the dentures with water when they are not being worn prevents warping. Storing them in an enclosed labeled cup prevents accidental disposal of the dentures. Cleaning with a weak bleach solution weekly may adversely affect the matrix of the dentures. The dentist should be consulted for the best cleaning techniques for dentures.

Which of the following are nurse-provided indirect care activities? (Select all that apply.) A) Delegating B) Documenting C) Evaluating new products D) Administering medications E) Providing client counseling

A, B, and C The correct options do not involve direct interaction with the client or family. The other options do require such direct interaction.

The nurse gathered the following assessment data. Which of these cues form a pattern? (Select all that apply.) A) Client is restless. B) Respirations are 24/min and irregular. C) Client states feeling short of breath. D) Fluid intake for 8 hours is 800 ml. E) Client has drainage from surgical wound. F) Client reports loss of appetite for over 2 weeks.

A, B, and C The data in items 1, 2, and 3—rapid irregular breathing, complaints of shortness of breath, and restlessness—form a pattern indicating that the client may be experiencing hypoxia, because all are signs and symptoms characteristic of this condition. The other information, although important, is not related to hypoxia.

Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary elimination? (Select all that apply.) A) Nocturia B) Frequency C) Urinary retention D) Inadequate urinary output E) Receipt of intravenous fluids F) Sensation of bladder fullness

A, B, and C The defining characteristics for Impaired urinary elimination according to NANDA include nocturia, frequency, and urinary retention. The other options are not defining characteristics from NANDA.

The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply): A) Difficulty staying asleep B) Extended time to fall asleep C) Feeling tired after a night's sleep D) Falling asleep at inappropriate times

A, B, and C These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia. Falling asleep at inappropriate times is indicative of narcolepsy.

The nurse begins to suspect a fecal impaction in a client who has not had a stool in 10 days when which of the following occurs? (Select all that apply.) A) The client feels nauseated. B) The client oozes liquid stool. C) The client has a rounded abdomen. D) The client has continuous bowel sounds

A, B, and D Nausea, liquid stool, and continuous bowel sounds are all symptoms of an impaction. Liquid stool can seep around the impaction. If stool cannot exit, there is a backup of gastrointestinal contents, which often results in nausea. Bowel sounds may be increased as the body attempts to push the impaction forward. A rounded abdomen by itself may indicate obesity or even ascites. For a rounded abdomen to be a symptom of an impaction, distention must be present.

The nurse is teaching a group of young (20- to 25-year-old) women how to prevent urinary tract infections (UTIs). Which of the following foods does the nurse recommend consuming to reduce the incidence of UTIs? (Select all that apply.) A) Prunes B) Cranberry juice C) Grapefruit juice D) Whole-grain breads

A, B, and D Prunes, cranberry juice, and whole-grain breads acidify the urine, which creates an inhospitable environment for pathogens. In addition, cranberry juice has been shown to decrease the adherence of bacteria to the bladder wall. Grapefruit juice has not demonstrated any value in preventing UTIs.

Hygienic care requires close contact with the client. The nurse initially uses which of the following to promote a caring therapeutic relationship? A) Assessment skills B) Therapeutic touch C) Fundamental skills D) Communication skills

A, C, and D Because hygienic care requires close contact with the client, the nurse uses communication skills to promote a caring therapeutic relationship and to take advantage of the time with the client for teaching and counseling.

To prevent the client from performing a Valsalva maneuver, the nurse might request a stool softener for a client with which of the following conditions? (Select all that apply.) A) Glaucoma B) Hypotension C) Cardiovascular disease D) Risk for increased intracranial pressure

A, C, and D The Valsalva maneuver can increase intracranial pressure, which is undesirable. It can also increase intraocular pressure and thus increase the risk for optic nerve damage. Hypotension is not aggravated by the Valsalva maneuver, but the maneuver can increase blood pressure, which could place a strain on the heart.

Which of the following assessment data indicate that the client's airway needs suctioning? (Select all that apply.) A) Drooling B) Production of thin, watery sputum C) Decreased coughing ability D) Secretions that clear with coughing E) Abnormal lung sounds only in left lower lobe

A, C, and E Suctioning is necessary when the client is unable to clear respiratory secretions from the airways. Signs that a client's airway needs suctioning include a change in respiratory rate or adventitious sounds, nasal secretions, gurgling, drooling, restlessness, gastric secretions or vomitus in the mouth, and coughing without clearance of secretions from the airway.

When determining a client's ability to perform instrumental activities of daily living, which of the following skills does the nurse assess? (Select all that apply.) A) Ability to cook meals B) Ability to feed oneself C) Ability to write checks D) Ability to bathe oneself E) Ability to take medications

A, C, and E The correct options are skills that allow the client to live independently in society. They may or may not be performed on a daily basis. The other options are activities of daily living.

S1 is heard best at the: A. 5th left intercostal space along the midclavicular line B. 3rd intercostal space to the left of the midclavicular line C. Second right intercostal space at the sternal border D. Second left intercostal space at the sternal border

A. 5th left intercostal space along the midclavicular line The S1 heart sound is best heard at the apex of the heart, at the fifth intercostal space along the midclavicular line. (An infant's apex is located at the third or fourth intercostal space just to the left of the midclavicular line)

The term gavage indicates: A. Administration of a liquid feeding into the stomach B. Visual examination of the stomach C. Irrigation of the stomach with a solution D. A surgical opening through the abdomen to the stomach

A. Administration of a liquid feeding into the stomach Gavage is the administration of a liquid feeding into the stomach.

The nurse would use which method of examination to assess for the presence of a bruit in the abdomen? A. Auscultation B. Percussion C. Palpitation D. Inspection

A. Auscultation Auscultation uses the sense of hearing to identify sounds that are normal and abnormal during the assessment. A bruit is an abnormal sound of the venous/arterial system that is only detectable by listening with a stethoscope. A bruit cannot be detected by percussion or inspection. The turbulent blood flow that is heard as a bruit would be palpated as a thrill.

Postural drainage to relieve respiratory congestion should take place: A. Before meals B. After meals C. At the nurse's convenience D. At the patient's convenience

A. Before meals Postural drainage is best performed before, rather after meals to avoid tiring the patient or inducing vomiting. The patient's safety supersedes the convenience in scheduling this procedure.

Leininger's theory of cultural care diversity and universality specifically addresses: A) Caring for clients from unique cultures B) Understanding the humanistic aspects of life C) Identifying variables affecting a client's response to a stressor D) Caring for clients who cannot adapt to internal and external environmental demands

A. Caring for clietns from unique cultures The goal of Leininger's theory is to provide the client with culturally specific nursing care, in which the nurse integrates the client's cultural traditions, values, and beliefs into the plan of care.

The nurse anticipates that a right-handed client with a fractured right arm will require assistance with activities of daily living. What skill is the nurse demonstrating? A) Cognitive skill B) Behavioral skill C) Interpersonal skill D) Psychomotor skill

A. Cognitive skill The nurse is using sound judgment and clinical decisions to provide individualization of care. A decision is made without direct interaction with the client but is based on knowledge about the client. No psychomotor skill is involved in this decision-making process. There is no such thing as a behavioral skill.

The assessment phase of the teaching process includes: A) Determining learning needs B) Setting priorities C) Selecting teaching methods D) Selecting teaching approach

A. Determining learning needs Information obtained during the assessment will determine what is necessary for the client to learn. Because the health status of the client may undergo changes, assessment for learning needs is an ongoing process. Setting priorities and selecting teaching methods are part of the planning phase. Selection of the teaching approach is part of the implementation phase.

A client tells the nurse, "I'm not happy with the way the patient care technician did my bath. He just seemed to be in a hurry and did not wash my back like I asked." The nurse decides to go talk with the technician to learn his side of the story as well. This is an example of: A. Fairness B. Curiosity C. Risk taking D. Responsibility

A. Fairness Fairness involves analyzing all viewpoints to understand the situation completely before making a decision. Curiosity gives the critical thinker the motivation to continue to ask questions and learn more. Risk taking involves trying different ways to solve problems.

The nursing assessment is which phase of the nursing process? A) First B) Second C) Third D) Fourth

A. First The nursing process cannot proceed unless the nurse first conducts a client assessment. The other phases of the nursing process occur after assessment.

A sudden redness of the skin is known as: A. Flush B. Cyanosis C. Jaundice D. Pallor

A. Flush Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin, mucous membranes and sclera caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon dioxide in the blood.

Theories that are broad and complex are: A) Grand theories B) Descriptive theories C) Middle-range theories D) Prescriptive theories

A. Grand theories Grand theories are described as broad and complex. Middle-range theories are limited in scope, less abstract, address specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena. Prescriptive theories address nursing interventions and predict the consequence of a specific intervention.

The nurse prepares a client for a lumbar puncture. Before the start of the procedure the nurse is sure to: A) Have the client void. B) Place the client in Sims' position. C) Premedicate the client with analgesics. D) Insert a peripheral intravenous (IV) catheter.

A. Have the client void The nurse takes care of physical needs (voiding) that could interrupt the procedure and possibly increase the risk of complications. The client assumes the fetal position or sits upright with arms over a bedside table. Because lidocaine is used in lumbar puncture, analgesics are not essential. Peripheral IV catheters are not required for this procedure.

The nurse asks the client whether the client has any allergies. This is an example of: A) Health history data B) Biographical information C) History of present illness D) Environmental history data

A. Health history data Known allergies are a part of historical data. Biographical data include age, address, occupation, work status, marital status, course of health care, and insurance. The history of the present illness includes when the symptoms began, whether they began suddenly or gradually, whether they come and go, and other information about the illness. The environmental history includes data about the client's home and working environments.

nurse routinely asks clients if they take any vitamins or herbal medications, encourages family members to bring in music that clients like to help them relax, and frequently prays with clients if that is important to them. The nurse is using which model of care? A) Holistic B) Health belief C) Transtheoretical D) Health promotion

A. Holistic The holistic model attempts to create conditions that promote optimal health. The holistic model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions. The health belief model addresses the relationship between a person's beliefs and behaviors. The transtheoretical model of change discusses a series of changes through which clients move, starting with precontemplation and ending maintenance. The health promotion model defines health as a positive, dynamic state and not merely the absence of disease.

Which of the following is a nursing diagnosis? A. Hypothermia B. Diabetes Mellitus C. Angina D. Chronic Renal Failure

A. Hypothermia Hyperthermia is a NANDA-approved nursing diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are medical diagnoses.

When assessing a patient's level of consciousness, which type of nursing intervention is the nurse performing? A. Independent B. Dependent C. Collaborative D. Professional

A. Independent Independent nursing interventions involve actions that nurses initiate based on their own knowledge and skills without the direction or supervision of another member of the health care team.

Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with man as the central focus? A. Martha Rogers B. Dorothea Orem C. Florence Nightingale D. Sister Callista Roy

A. Martha Rogers Martha Roger's life process model views man as an evolving creature interacting with the environment in an open, adaptive manner. According to this model, the purpose of nursing is to help man achieve maximum health in his environment.

Which of the following is inappropriate nursing action when administering NGT feeding? A. Place the feeding 20 inches above the point of insertion of NGT B. Introduce the feeding slowly C. Instill 60ml of water into the NGT after feeding D. Assist the patient in fowler's position

A. Place the feeding 20 inches above the point of insertion of NGT The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting

To promote correct anatomic alignment in a supine patient, the nurse should: A. Place the patient's feet in dorsiflexion B. Place a pillow under the patient's knees C. Hyperextend the patient's neck D. Adduct the patient's shoulder

A. Place the patient's feet in dorsiflexion Anatomic alignment prevents strain on body parts, maintains balance, and promotes physiologic functioning. To promote this position, the nurse should place the feet in dorsiflexion (at right angles to the legs).

A postsurgical client calls for a nurse and asks to be repositioned. The nurse finds that the client's drainage tube is disconnected and the intravenous (IV) line has 100 ml of fluid remaining. Which of the following should be performed first? A) Reconnect the drainage tube. B) Inspect the condition of the IV dressing. C) Improve the client's comfort and turn her to her side. D) Go to the medication room and obtain the next IV fluid bag.

A. Reconnect the drainage tube The nurse should reconnect the drainage tube first to ensure that the wound is properly draining. The client should then be turned (with care taken to ensure that the tubing remains connected), followed by replacing the IV fluid bag, checking the IV site, and restarting the IV fluid. With 100 ml left, the nurse has a bit of time to replace the IV bag before it runs dry, so caring for the client's wound and comfort should come first.

The usual sequence for assessing the bowel is: A. Right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant B. Right lower lobe, right upper lobe, left upper lobe, left lower lobe C. Right hypochondriac, left hypochondriac and umbilical regions D. Rectum, pancreas, stomach and liver

A. Right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant This sequence follows the anatomy of the bowel. The lobes are parts of the lung. the right and left hypochondriac and the umbilical area are three of the nine regions of the abdomen.

Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following? A) Safety B) Nurse staffing C) Confidentiality D) Adequate pain relief

A. Safety Client safety is an environmental factor and is always the first concern. Pain relief, staffing, and confidentiality are important but are not environmental factors.

A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first? A. Stop the infusion B. Call the attending physician C. Slow that infusion to 20 ml/hr D. Place a cold towel on the site

A. Stop the infusion The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site.

The nurse preparing to assess for jugular venous distention (JVD) places the client into which position? A. Supine with head of the bed elevated 30 degrees B. Supine with neck placed downward on chest C. High-fowler's with head elevated upward D. Side-lying with no pillows under the head

A. Supine with head of the bed elevated 30 degrees To assess for jugular venous distention (which indicates fluid volume overload), the client should be lying supine with the head elevated to 30 degrees (low Fowler's). The nurse assesses the highest point of distention of the internal jugular vein in centimeters in relation to the sternal angle, the point at which the clavicles meet. The other positions listed would not aid in this physical assessment technique.

A client who is having chest pain is to undergo emergency cardiac catheterization. Which of the following is the most appropriate teaching approach in this situation? A) Telling approach B) Entrusting approach C) Reinforcing approach D) Participating approach

A. Telling approach The telling approach is used when teaching limited information, such as in an emergent situation. The entrusting approach provides the client the opportunity to manage self-care. In the participating approach, the nurse and client set objectives and become involved in the learning process together. Reinforcement requires the delivery of a stimulus that increases the probability of a response.

A 72-year-old man diagnosed with chronic obstructive pulmonary disease 5 years ago has been participating for the last 2 years in a pulmonary rehabilitation exercise class offered by the local hospital at a fitness facility. This is what level of prevention? A) Tertiary prevention B) Primary prevention C) Secondary prevention D) Quaternary prevention

A. Tertiary prevention Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce negative impacts and complications. Primary prevention is true prevention that precedes disease and involves clients considered physically and emotionally healthy. Secondary prevention is aimed at individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Quaternary prevention is not a recognized term.

A client was in pain following surgery. The nurse administered the prescribed analgesics, but the client's pain rating stayed the same (8 out of 10). What should the nurse recognize? A) The pain plan needs changing. B) The client is overrating the pain. C) Complications from surgery are occurring. D) Nonpharmacological pain-relieving strategies are now appropriate.

A. The pain plan needs changing The current pain medications are not effectively relieving the pain. The nurse needs to call the physician and discuss changing the medication is some way (type, dose, frequency, formulation). Pain is what the client says it is. There is no objective way to measure pain. The clinician must accept the client's report of pain. Nonpharmacological strategies are adjuncts to the pain plan. They are not to be used in place of pain medications. Pain following surgery is an expectation.

Nursing theories focus on the phenomena of nursing and nursing care. Which of the following is true of phenomena? A) They are aspects of reality that can be consciously sensed or experienced. B) They convey the general meaning of concepts in a manner that fits the theory. C) They are statements that describe concepts or connect two concepts that are factual. D) They are mental formulations of an object or event that come from individual perceptual experience.

A. They are aspects of reality that can be consciously sensed or experienced. Phenomena are defined as aspects of reality that can be consciously sensed or experienced.

The nurse listens to Mrs. Sullen's lungs and notes a hissing sound or musical sound. The nurse documents this as: A. Wheezes B. Rhonchi C. Gurgles D. Vesicular

A. Wheezes Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration.

The nurse asks a client, "Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a client interview? A) Working B) Orientation C) Termination

A. Working The nurse's questions exemplify the working phase of the interview.

When assessing darkly pigmented skin for bruising, the nurse is sure to do which of the following? (Select all that apply.) A) Use a fluorescent lamp. B) Look for grayish, eggplant-colored areas. C) Compare one side of the body with the other. D) Use the back of a gloved hand to feel for skin temperature.

B and C Comparing sides of the body will allow the nurse to more easily see variations in skin color. Bruising will not appear red as in pink or white skin but will show variations of blue, purple, or gray. Fluorescent lamps can give the skin a bluish tone and thus hinder skin assessment in darkly pigmented skin. To accurately assess the temperature of the skin, no gloves should be used.

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and anxiety. The nurse helps the client to breathe better by doing which of the following? (Select all that apply.) A) Implementing guided imagery B) Instructing the client to perform pursed-lip breathing C) Elevating the head of the bed to semi-Fowler's or Fowler's position D) Encouraging the client to drink a full glass of water to liquify secretions

B and C Elevating the head of the bed to Fowler's position (45-degree angle) or semi-Fowler's position (30- to 45-degree angle) causes the diaphragm to lower from gravity and thus increases the space for lung expansion. Pursed-lip breathing prolongs exhalation and maintains the alveoli open longer, thus extending the period of oxygen and carbon dioxide exchange. Too high an elevation of the head of the bed could force the diaphragm into the thorax and reduce lung expansion. Fluids could help liquify the pulmonary secretions in the future, but right now the client needs more acute care. Guided imagery may help in the future, but now is not the time to implement this intervention.

A client with a Salem sump tube begins to drain stomach contents from the blue "pigtail." Which nursing actions would be appropriate for the nurse to implement at this time? (Select all that apply.) A) Clamp the blue pigtail. B) Attach suction to the blue pigtail. C) Irrigate the large lumen with saline. D) Position the blue pigtail at the level of the client's ear.

B and D Irrigation determines the patency of the main sump drain. If it is obstructed, stomach contents can and will exit via the blue pigtail. Positioning the blue pigtail above the level of the stomach minimizes its becoming a drain. One should never clamp or apply suction to the blue pigtail, because that would eliminate its function as an air vent that prevents the gastric mucosa from being sucked into the sump's eyelets.

The nurse suspects left-sided heart failure in a newly admitted client when the nurse notes which of the following symptoms? (Select all that apply.) A) Distended neck veins B) Bilateral crackles in the lungs C) Weight gain of 2 lb in past 2 days D) Shortness of breath, especially at night

B and D Left-sided heart failure results in ineffective ejection of blood from the left ventricle. This causes a backup of blood into the lungs. Thus, symptoms of left-sided heart failure are usually related to the lungs.

When suctioning secretions that are collecting in an endotracheal tube, the nurse does not apply suction for longer than: A) 5 seconds B) 10 seconds C) 15 seconds D) 20 seconds

B) 10 seconds Applying suction for too long can result in complications such as hypoxemia and cardiac dysrhythmias. Thus the nurse is always aware of the length of time that suctioning is applied to an airway. If the suctioning time is too short, the suction catheter may not remove the secretions. If the suctioning time is too long, hypoxemia and/or cardiac dysrhythmias could result.

If an infectious disease can be transmitted directly from one person to another, it is: A) A susceptible host B) A communicable disease C) A portal of entry to a host D) A portal of exit from the reservoir

B) A communicable disease If an infectious disease is transmitted directly from one person to another, it is a communicable disease. Portals of entry and exit are the mechanisms of disease transmission. A susceptible host is a person who can acquire an infection.

When irrigating a colostomy, the nurse is sure to use which of the following equipment? A) An enema set B) A cone-tipped irrigator C) A 50-ml irrigation syringe D) A 16-French Foley catheter with a 30-ml balloon

B) A cone-tipped irrigator Using a cone-tipped irrigator is important to prevent irritation of or injury to the stoma. It prevents bowel perforation and backflow of irrigating solution. The other options are inappropriate for colostomy irrigation because they could cause injury to the bowel mucosa and/or allow backflow of the irrigating solution.

The nurse incorporates what priority nursing intervention into a plan of care to promote sleep for a hospitalized client? A) Have client follow hospital routines. B) Avoid awakening client for nonessential tasks. C) Give prescribed sleeping medications at dinner. D) Turn television on low to late-night programming

B) Avoid awakening client for nonessential tasks. Hospitals and extended care facilities usually do not adapt care to an individual's sleep-wake cycle preferences. The nurse should attempt to avoid awakening sleeping clients for nonessential tasks to try and preserve their sleep cycles. The other options are incorrect.

In addition to bathing, which of the following may best promote client comfort? A) Snack B) Back rub C) Books on tape D) Postural drainage

B) Back rub Back rubs promote relaxation, relieve muscular tension, and decrease the perception of pain. Audio books and snacks may provide temporary comfort. Postural drainage is indicated for specific individuals.

A parent calls the pediatrician's office frantic because her 2-year-old son drank a bottle of cleaner. Which of the following is the most important instruction the nurse can give to this parent? A) Give the child milk. B) Call the poison control center. C) Give the child syrup of ipecac. D) Take the child to the emergency department.

B) Call the poison control center. The poison control center will direct all care given to a child who has ingested a substance. Based on the description of the poison, poison control center staff will tell the parent whether the child needs to go to the emergency department and what substances should be given to the child

Upon examining the feet of an older adult client with type 2 diabetes, the nurse notices long, thick nails. The client says that the nails catch on his socks and asks the nurse to cut them. The most appropriate intervention for the nurse to implement is: A) Soaking the feet in warm water before trimming the toenails B) Calling the physician and asking for a foot care nurse consult C) Providing toenail cutters to the client, because nurses are not allowed to do this procedure D) Instructing an unlicensed assistant (UAP) to cut the toenails after the morning care

B) Calling the physician and asking for a foot care nurse consult Foot and nail care are considered part of the client's regular hygiene routine, except for clients with diabetes mellitus. Because of impaired circulation to the feet, cutting of toenails, particularly if they are thickened from long-standing fungal infections, is risky and could cause an infection. Soaking the feet of a client with type 2 diabetes is not recommended because of the increased risk for infection. A client with type 2 diabetes most likely also has impaired vision, and the client could cut the skin or break a toenail if the client attempted to cut the toenails himself or herself, which could result in a serious infection. In many institutions registered nurses are not permitted to cut the toenails of a client with type 2 diabetes; therefore, instructing the UAP to perform this task is inappropriate.

A client asks why smoking is a major risk factor for heart disease. In formulating a response, the nurse incorporates the understanding that nicotine: A) Causes vasodilation B) Causes vasoconstriction C) Increases the level of high-density lipoproteins D) Increases the oxygen-carrying capacity of hemoglobin

B) Causes vasoconstriction Nicotine causes vasoconstriction, which restricts blood flow to the heart and peripheral tissues and increases the risk of hypertension and subsequently heart disease as a complicating factor. Nicotine does not cause vasodilation. Nicotine decreases the oxygen-carrying capacity of hemoglobin. Nicotine decreases the level of high-density lipoproteins and elevates the level of harmful low-density lipoproteins, which leads to atherosclerosis.

The nurse tells the client, "I'm not sure I understand what you mean by 'sicker than usual.' What is different now?" The nurse is using the therapeutic technique of: A) Focusing B) Clarifying C) Paraphrasing D) Providing information

B) Clarifying Clarifying gives the client a chance to be more specific or give more information. Paraphrasing means restating another's message briefly in one's own words. The nurse is not providing information in the remarks given. Focusing is used to bring attention to key concepts or elements in a message.

The nurse is instructing the client about the use of opioids for pain relief. Included in the teaching is the fact that opioids may cause: A) Headaches B) Constipation C) Hypertension D) Muscle weakness

B) Constipation Constipation is a known side effect of opioids to which the client often does not become tolerant. Headaches, hypertension, and muscle weakness are not known side effects of opioids.

To assist an adult client to sleep better, the nurse recommends which of the following? (Select all that apply.) A) Eating a large meal 1 hour before bedtime B) Consuming a small glass of warm milk at bedtime C) Drinking a glass of wine just before retiring to bed D) Performing mild exercises 30 minutes before going to bed

B) Consuming a small glass of warm milk at bedtime A small glass of milk relaxes the body and promotes sleep. Alcohol, large meals, and exercising all within 1 to 2 hours of bedtime have insomnia-producing effects and may, in fact, stimulate wakefulness. Large meals could also produce indigestion.

As a result of the adaptation response to surgery, the nurse expects that for the first 1 to 2 days after the client's surgery the client's urine output will: A) Increase B) Decrease

B) Decrease The stress response releases an increased amount of antidiuretic hormone, which increases water reabsorption. Stress also elevates aldosterone levels, which causes sodium and water retention. Both of these physiological responses reduce urine output.

Soon after the client's abdominal surgery the nurse includes in the plan of care which of the following interventions, which is essential for promoting peristalsis? A) Consumption of a high-fiber diet B) Early ambulation C) Restriction of fluid intake D) Administration of large doses of opioids

B) Early ambulation Early ambulation is essential for maintaining peristalsis through improved abdominal muscle tone and stimulation. Large doses of opioids may suppress peristalsis. The dosage of opioid should be that which adequately controls pain with the fewest side effects. A high-fiber diet is inappropriate immediately following surgery. The bowel is inflamed from surgery. Restriction of fluids could contribute to constipation. Intake of fluids should be started as soon after surgery as possible, once bowel sounds have returned.

A client is isolated because the client has pulmonary tuberculosis. The nurse notes that the client seems angry but knows this is a normal response to isolation. The best intervention is to: A) Provide a dark, quiet room to calm the client. B) Explain the isolation procedures and provide meaningful stimulation. C) Reduce the level of precautions to keep the client from becoming angry. D) Limit family and other caregiver visits to reduce the risk of spreading the infection.

B) Explain the isolation procedures and provide meaningful stimulation. When a client is in isolation, the nurse should take measures to improve the client's stimulation and make sure to explain the isolation procedures. Darkening the room can increase the sense of isolation. The nurse should not change the isolation level but should provide plenty of emotional support and make time for the client to prevent a sense of isolation. As long as family and caregivers follow infection precautions, there is no reason to limit contact with these individuals.

Carbon monoxide (CO) is a toxic inhalant that decreases the oxygen-carrying capacity of blood by: A) Forming a weak bond with hemoglobin B) Forming a strong bond with hemoglobin C) Forming a weak bond with carbamino compounds D) Forming a strong bond with carbamino compounds

B) Forming a strong bond with hemoglobin CO is the most common toxic inhalant and decreases the oxygen-carrying capacity of blood. In CO toxicity, hemoglobin strongly binds with carbon monoxide, creating a functional anemia. Because of the strength of the bond, carbon monoxide does not easily dissociate from hemoglobin, which makes hemoglobin unavailable for oxygen transport.

Conditions such as shock and severe dehydration resulting from extracellular fluid loss cause: A) Hypoxia B) Hypovolemia C) Hypervolemia D) Uncontrolled bleeding

B) Hypovolemia Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume (hypovolemia).

The nurse teaches a client taking phenytoin (Dilantin), an anticonvulsant, that this group of medications causes which symptom of a sleep problem? A) Nocturia. B) Increased daytime sleepiness. C) Increased awakening from sleep. D) Increased difficulty falling asleep.

B) Increased daytime sleepiness. The anticonvulsants can cause increased daytime sleepiness because they decrease REM sleep time. They do not cause nocturia, increased awakenings, or increased difficulty falling asleep.

The family of the nurse's confused, ambulatory client insists that all four side rails be up when the client is alone. The best way to handle this situation is to: A) Ask them to stay with the client at all times. B) Inform them of the risks associated with side rail use. C) Thank them for being conscientious and put the four rails up. D) Provide the client with a one-to-one sitter while the side rails are up

B) Inform them of the risks associated with side rail use. The use of side rails when a client is disoriented will cause more confusion and further injury. A confused client who is determined to get out of bed may attempt to climb over the side rail or climb out at the foot of the bed, and may fall or experience other injury. After the nurse has this discussion with the family, then the nurse should perform a thorough nursing assessment and develop a plan to ensure the client's safety.

1. A nursing student gives herself positive messages regarding her ability to do well on a test. This is an example of what level of communication? A) Public B) Intrapersonal C) Interpersonal D) Transpersonal

B) Intrapersonal Intrapersonal communication is a powerful form of communication that occurs within an individual. Interpersonal communication takes place between people. Transpersonal communication occurs within a person's spiritual domain. Public communication is interaction with an audience.

A pregnant client mentally rehearses giving birth in her mind. This is an example of: A) Metacommunication B) Intrapersonal communication C) Interpersonal communication D) Transpersonal communication

B) Intrapersonal communication Intrapersonal communication is also called self-talk, self-instruction, and inner thought. Self-instruction can provide mental rehearsal for difficult tasks, such as labor and delivery, so individuals can deal with them more effectively. Interpersonal communication is one-to-one interaction that often occurs face to face. Transpersonal communication is interaction that occurs in a person's spiritual domain, such as through prayer or meditation. Metacommunication is looking at the deeper meaning of what is being said.

Which of the following instructions is it crucial for the nurse to give to both the client and family members when the client is about to be started on morphine delivered via a patient-controlled analgesia (PCA) device? A) The PCA button should not be pushed until the pain is severe. B) Only the client should push the PCA button. C) The nurse should be notified when the button is pushed. D) The PCA system prevents overdoses from occurring.

B) Only the client should push the PCA button. Only the client should push the PCA button, because the client should be the one to decide when medication is needed. The client should use the button whenever there is pain and should not wait until the pain is severe. The nurse does not need to be notified when the button is pushed unless the medication is not relieving pain. The PCA system does prevent accidental overdoses, but the most important feature is that the client controls the analgesia.

A client with a history of a stoke that left her confused and unable to communicate has returned from the interventional radiology department after placement of a gastrostomy tube. The physician's order reads: "Vicodin 1 tablet, per tube, every 4 hours as needed." Which is the best action by the nurse? A) Take no action because the order is appropriate. B) Request to have the order changed to around-the-clock administration for the first 48 hours. C) Begin the Vicodin when the client shows nonverbal signs of pain. D) Ask for a change of medication to meperidine (Demerol) 50 mg by intravenous push every 3 hours as needed.

B) Request to have the order changed to around-the-clock administration for the first 48 hours. This client is nonverbal and cannot communicate her pain level. Changing the client's medication to around-the-clock administration for 48 hours allows the client to receive some continual pain relief. If the client begins to show nonverbal symptoms of pain, this approach needs to be reconsidered. Meperidine is typically not used in more than a single dose.

When working with an older adult, the nurse should remember to avoid: A) Touching the client B) Shifting from subject to subject C) Allowing the client to reminisce D) Asking the client how he or she feels

B) Shifting from subject to subject The nurse should avoid shifting from subject to subject, because it can create confusion. All individuals require touch. Allowing older adults to reminisce can be helpful and therapeutic. Asking a client how he or she feels is a method of opening communication.

When providing health maintenance teaching to new employees in the food-handling department, the nurse emphasizes the need to perform hand hygiene after using the bathroom to prevent: A) Food poisoning B) Spread of hepatitis A C) Bacterial food infections D) Salmonella contamination

B) Spread of hepatitis A The hepatitis A virus is spread via fecal contamination of food, water, or milk. It is essential that food handlers wash their hands anytime they use the bathroom. Food poisoning can be due to bacterial contamination of food from a variety of sources, but not usually feces. Salmonella contamination usually arises from uncooked eggs.

A client is being discharged to home with an order for an around-the-clock opioid for relief of chronic back pain. Because of this drug regimen, for which class of medication does the nurse request an order? A) Stool softener B) Stimulant laxative C) H2 receptor blocker D) Proton pump inhibitor

B) Stimulant laxative All clients receiving opioid therapy should also be placed on a bowel program to ensure that constipation related to opioid use is avoided. The other medications are not required with around-the-clock opioid use.

A client with diabetes is hospitalized with a sore on his foot that has failed to heal. The nurse is gathering a videotape and some printed material on diabetes to begin teaching the client when he calls the nurse asking for something to decrease his pain. In terms of the elements of the communication process, the referent in this situation is: A) The nurse B) The client's pain C) The videotape and printed material on diabetes D) The client's and nurse's sociocultural background

B) The client's pain A referent motivates one person to communicate with another. In this case, sensations and perceptions of pain initiated communication. The videotape and printed material are means of conveying and receiving messages, called channels. The nurse is the receiver, the person who receives and decodes the message. The sociocultural background of the client and nurse are interpersonal variables that influence communication.

Which of the following illustrates the focus of the nurse's interaction during the working phase of the nurse-client helping relationship? A) The nurse says to the client, "Hi, Mr. Owen. My name is Gwen, and I'll be your nurse today." B) The nurse asks the client, "What do you think would help you recover more quickly from your surgery?" C) The nurse asks another nurse while receiving a report, "What did the laboratory report indicate for Mr. Owen?" D) The nurse tells the client, "My shift will be over in about 30 minutes, but I'll see you again tomorrow. You did really well with physical therapy today."

B) The nurse asks the client, "What do you think would help you recover more quickly from your surgery?" During the working phase, the nurse helps the client with self-exploration and goal setting. Option 4 illustrates the termination phase, in which the nurse reminds the client that termination is near and evaluates goal achievement with the client. Option 3 exemplifies the preinteraction phase, in which the nurse reviews available data and talks with other caregivers who may have information about the client. Option 1 demonstrates the orientation phase, in which the nurse begins to establish a relationship that initially is superficial using introductions and social talk. The nurse sets the tone for the relationship in a caring manner and clarifies the client's and nurse's roles.

The nurse has just admitted a client to rule out active hepatitis B. The client is confused, spitting and scratching everyone who enters the room. The nurse should: A) Wait an hour until the client calms down and then use gloves when touching the client. B) Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment. C) Administer a sedative and then perform the assessment after the client is asleep; no precautions would be needed. D) Realize that isolation equipment might further confuse the client and avoid using a face mask and shield but use gown and gloves.

B) Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment. Hepatitis virus is a blood-borne virus, but the client is increasing the risk of cross contamination by spitting (saliva can be a source of bacterial contamination) and scratching others, which can break the skin and become a source of risk. All of the barriers listed would minimize cross contamination from the client to the nurse. Even though gloves may be all that is needed because of limited contact with the client, after an hour the client will remain confused and may not understand. The client may become aggressive again and spit or scratch, and other barriers are needed to stop that source of possible risks. A sedative may be given if needed, but trying to perform an assessment when the client is asleep is not appropriate and will prevent the nurse from successfully establishing rapport with the client. Although masks and shields might be frightening to some confused clients, if the client is spitting and body fluids could be exchanged, a barrier should still be used.

The nurse is providing health teaching for a client using herbal compounds such as valerian for sleep. What points need to be included? Check all that apply. A) Can cause urinary retention B) Should not be used indefinitely C) May cause diarrhea and anxiety D) May interfere with prescribed medications E) Over time they can lead to further sleep problems F) Are not regulated by the Food and Drug Administration (FDA)

B, D, E, and F Caution clients to use herbal products carefully because the FDA does not regulate them and they may interact with prescription medication. Over time, the use of herbal compounds can lead to further sleep problems, so they should not be used indefinitely. Urinary retention, diarrhea, and anxiety are generally not side effects of herbal compounds used for sleep. However, older adults may experience urinary retention with the use of over-the-counter antihistamines.

The nurse teaches clients with a new colostomy that they can eat whatever foods they like but that which of the following foods typically produce gas and should be consumed cautiously? (Select all that apply.) A) Pasta B) Beans C) Garlic D) Onions E) Cauliflower

B, D, and E Foods affect clients differently. However, some foods appear to produce more gas than others. Warning clients about these traditional gas producers will alert them to be aware of the possible problem and allow them to make informed choices. Garlic and pasta are not known to produce excessive gas.

A client says, "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the client through the stages of change toward regular exercise? A) "Walking is OK. I really think running is better." B) "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?" C) "Yes, I want you to begin walking. Walk for 30 minutes every day and start eating more fruits and vegetables, too." D) "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes walking if you are going to do any good."

B. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?" This option supports the preparation stage in which the client is beginning to consider making small changes. The other options are not good ones for this client.

The nurse in charge measures a patient's temperature at 101 degrees F. What is the equivalent centigrade temperature? A. 36.3 degrees C B. 37.95 degrees C C. 40.03 degrees C D. 38.01 degrees C

B. 37.95 To convert °F to °C use this formula, ( °F - 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5.

Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the patient has had pain for more than: A. 3 months B. 6 months C. 9 months D. 1 year

B. 6 months Chronic pain is usually defined as pain lasting longer than 6 months.

The nursing theory that emphasizes the delivery of nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family is: A) Rogers' theory B) Abdellah's theory C) Henderson's theory D) Nightingale's theory

B. Abdellah's theory The question describes the nursing theory developed by Fay Abdellah and others. Rogers' theory considered the individual as an energy field existing within the universe. Henderson's theory defines nursing as "assisting the individual, sick, or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death." Nightingale viewed nursing as providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition.

According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after oxygen? A. Safety B. Activity C. Love D. Self esteem

B. Activity According to Maslow, activity is one of the man's most basic physiologic needs, along with oxygen, shelter, food, water, thirst, sleep and temperature maintenance.

The nursing diagnosis Hypothermia is an example of which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis

B. Actual nursing diagnosis An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. The term readiness is present in a wellness nursing diagnosis. A potential nursing diagnosis is a risk for diagnosis.

The correct site at which to verify a radial pulse measurement is the: A. Brachial artery B. Apex of the heart C. Temporal artery D. Inguinal site

B. Apex of the heart The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly.

When teaching older adults, the nurse should: A) Speak in a loud tone of voice. B) Begin and end with the most important information. C) Avoid repeating information to reduce confusion. D) Include as much information as possible in each teaching session.

B. Begin and end with the most important information Short-term memory is often reduced in older adults; therefore, repeating important information, and especially presenting it at the beginning and end, enhances retention. Speech at lower voice levels is better understood by the older adult. Repeating information does not create confusion but rather facilitates learning in the older adult. Older adults may have slower cognitive function and will remember more effectively if the information is paced properly.

A client's wound is not healing and appears to be worsening with the current treatment. What is the first option the nurse should consider? A) Notifying the physician B) Calling the wound care nurse C) Consulting with another nurse D) Changing the wound care treatment

B. Calling the wound care nurse Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. Notifying the physician may be appropriate after the nurse decides on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. Unless the nurse is knowledgeable in wound management, changing the wound care treatment could delay wound healing. Also, the current wound management plan might have been ordered by the physician. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.

Which of the following is the most accurate information to give a nurse during change-of-shift reporting? A) Client refuses to take medications. B) Client reports sharp pain in left anterior knee. C) Client encouraged to consume more fluids. D) Client expressed concern about pending surgery.

B. Client reports sharp pain in elft anterior knee The information in option 2 represents objective data that the nurse can use as part of baseline information. "Encouraged" and "more" are vague terms. "Concern" is also vague; relating the exact concern would be more accurate. Option 1 may be true, but accurate data would also report why the client refused medication.

Interdisciplinary care plans represent: A) All nursing personnel having input in the care plan. B) Contributions of all disciplines in caring for the client. C) The client's express wishes and advance directives. D) Physicians and nurses working together to develop a plan of care.

B. Contributions of all disciplines in caring for the client Interdisciplinary care plans include the contributions of all disciplines involved in the patient's care. The client's advance directives and express wishes may be included, as well as nursing and physician input, but other involved disciplines also contribute their plans.

7. When discussing the client's care with a nurse's aide, the nurse instructs the aide to report any coughing during meals in the client, who recently experienced a stroke and requires feeding. In this situation the nurse is acting as which of the following? A) Educator B) Delegator C) Client advocate D) On-the-job trainer

B. Delegator The nurse is delegating the task of feeding to the aide but is also providing directions.

6. Which theories describe an orderly process beginning with conception and continuing through death? A) Systems theories B) Developmental theories C) Interdisciplinary theories D) Stress and adaptation theories

B. Developmental theories Developmental theories discuss human growth from conception to death. The other options are incorrect

The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to do which of the following? A) Implement the specialist's recommendations. B) Discuss and review advised strategies with the CNS. C) Report the recommendations to the primary physician. D) Clarify the suggestions with the client and family members.

B. Discuss and review advised strategies wtih the CNS Because the primary nurse requested the consultation, it is important that the primary nurse and the CNS communicate and discuss recommendations. The primary nurse can then accept or reject the CNS's recommendations. A consultation requires review of the recommendations but not immediate implementation. Reporting the recommendations to the physician would be appropriate after the nurse first talks with the CNS about recommended changes in the plan of care and the rationale. Only then should the primary nurse call the physician. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. It is better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.

Which of the following nursing theorists developed a conceptual model based on the belief that all persons strive to achieve self-care? A. Martha Rogers B. Dorothea Orem C. Florence Nightingale D. Sister Callista Roy

B. Dorothea Orem Dorothea Orem's conceptual model is based on the premise that all persons need to achieve self-care. She also views the goal of nursing as helping the patient to develop self-care practices to maintain maximum wellness.

When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including which of the following? A) Apply a cold pack to the tibia. B) Elevate the leg 5 inches above the heart. C) Perform range-of-motion movement with right leg every 4 hours. D) Administer aspirin 325 mg every 4 hours as needed.

B. Elevate the leg 5 inches above the heart Elevation of the leg does not need a physician's order. Applying a cold pack and administering medication do require a physician's order. Range-of-motion movement of the fractured tibia is inappropriate.

If a patient sues a nurse for malpractice, the patient must be able to prove: A. Error, proximal cause, and lack of concern B. Error, injury and proximal cause C. Injury, error and assault D. Proximal cause, negligence and nurse error

B. Error, injury and proximal cause Three criteria must be met to establish malpractice: a nursing error, a patient injury, and a connection between the two.

Nurse Cathy on the other hand, knows the case immediately even before a diagnosis is done. Based on Benner's theory she is a/an: A. Novice B. Expert C. Competent D. Advanced beginner

B. Expert The ability to perceive something without further evidence is the development of intuition and is seen in Expert nurses. A novice nurse is governed by rules and usually inflexible. Competent nurses are planning nursing care consciously. Advanced beginners demonstrate acceptable performance.

A theory is a set of concepts, definitions, relationships, and assumptions that: A) Formulates legislation B) Explains a phenomenon C) Measures nursing functions D) Reflects the domain of nursing practice

B. Explains a phenomenon A theory is a set of concepts, definitions, relationships, and assumptions that explains a phenomenon. Theories do not formulate legislation, measure nursing functions, or reflect any domain of nursing practice.

A client needs to learn how to administer a subcutaneous injection. The nurse knows the client is ready to learn when the client: A) Has walked 400 feet B) Expresses the importance of learning the skill C) Can see and understand the markings on the syringe D) Has the dexterity needed to prepare and inject the medication

B. Expresses the importance of learning the skill When the client can verbalize the need to learn, the client is ready to learn to read the markings on the syringe, and the nurse can assess whether the client has the dexterity to perform the injection. The ability to walk 400 feet is not a prerequisite for learning about subcutaneous injection.

11. A person's ideas, convictions, and attitudes about health and illness can be described as: A) Moral beliefs B) Health beliefs C) Holistic views D) Negative health behaviors

B. Health beliefs Health beliefs are an individual's perceptions of health or illness, which may be based on factual information or misinformation, common sense or myths, or reality or false expectations. Moral beliefs are learned behaviors that are in accordance with the principles of right or wrong. Holistic views consider the emotional and spiritual well-being of the individual. Negative health behaviors include behaviors that are typically harmful to health, such as smoking, drug or alcohol abuse, poor diet, and refusal to take appropriate medications.

Clients maintain health or enhance their health by routine exercise and proper nutrition. This is known as: A) Illness B) Health promotion C) Control of external variables D) Wellness education

B. Health promotion Health promotion activities help clients maintain and enhance their present level of health. Wellness education instructs persons on how to care for themselves in healthy ways and includes topics such as physical awareness, stress management, and self-responsibility. Illness is defined as poor condition or disease. External variables are outside factors that influence a person's health beliefs and practices. They include family practices, socioeconomic factors, and cultural background.

Different attitudes about illness cause people to react in different ways when illness does occur. Medical sociologists call the reaction to illness: A) Health belief B) Illness behavior C) Health promotion D) Illness prevention

B. Illness behavior Illness behavior is the client's reaction to illness. The other three options are models of health

A 34-year-old client had a surgical repair of an abdominal hernia in the morning. At 12 noon, the nurse records the client's vital signs on the recovery room flow sheet. What is this an example of? A) Psychomotor skill B) Indirect care measure C) Physical care technique D) Anticipating complications

B. Indirect care measures Recording vital signs is an example of indirect care. Taking vital signs is an example of a psychomotor skill. Anticipating complications is a cognitive skill that is an assessment skill. Recording vital signs is a direct care measure and not a physical care technique.

During application of medication into the ear, which of the following is inappropriate nursing action? A. In an adult, pull the pinna upward B. Instill the medication directly into the tympanic membrane C. Warm the medication at room or body temperature D. Press the tragus of the ear a few times to assist flow of medication into the ear canal

B. Instill the medication directly into the tympanic membrane During the application of medication it is inappropriate to instill the medication directly into the tympanic membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.

When calling a nurse consultant about a difficult client-centered problem, which of the following should the primary nurse report? A) Client's concern about the current treatment B) Length of time current treatment has been in place C) Spouse's reaction to the client's current treatment D) Physician's reluctance to change the current treatment plan

B. Length of time current treatment has been in place Reporting the length of time the current treatment has been used gives the consulting nurse facts that will influence formulation of a new plan. The other options are subjective and emotional issues or conclusions about the current treatment plan and may bias the nurse consultant's decision regarding a new treatment plan.

Which of the following characteristics of a goal is missing from the statement "Client will ambulate daily"? A) Observable B) Measurable C) Client centered D) Singular goal or outcome

B. Measurable Goals must be measurable, such as "Client will ambulate 15 feet daily." The other characteristics are met in this goal statement.

Mr. Jose is admitted to the hospital with a diagnosis of pneumonia and COPD. The physician orders an oxygen therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is by: A. Croupette B. Nasal cannula C. Nasal catheter D. Partial rebreathing mask

B. Nasal cannula The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and drink.

The nurse should take a rectal temperature of a patient who has: A. His arm in a cast B. Nasal packing C. External hemorrhoids D. Gastrostomy feeding tubes

B. Nasal packing A rectal temperature is usually recommended whenever an oral temperature is contraindicated (e.g. the patient who have undergone oral or nasal surgery, infants and those who have history of seizures, etc.). However, a rectal temperature is contraindicated in patients having rectal disease, rectal surgery or diarrhea)

Formulating a nursing diagnosis is a joint function of: A. Patient and relatives B. Nurse and patient C. Doctor and family D. Nurse and doctor

B. Nurse and patient Although diagnosing is basically the nurse's responsibility, input from the patient is essential to formulate the correct nursing diagnosis.

Which of the following is subjective information to be entered in the client's medical record? A) Skin warm and dry. B) Pain intensity 8 out of 10. C) Breath sounds clear to auscultation. D) Amber urine in sufficient quantities.

B. Pain intensity 8 out of 10 Pain is purely a subjective phenomenon. Although the pain intensity rating is an objective number, it depends on the client's report. The other options are objective data.

10. A nurse teaches the importance of folic acid intake to a group of pregnant women. This is considered which level of preventive care? A) Illness behavior B) Primary prevention C) Tertiary prevention D) Secondary prevention

B. Primary prevention Primary prevention is considered true prevention. It aims at maintaining physical and emotional health in an already healthy individual.Primary prevention is considered true prevention. It aims at maintaining physical and emotional health in an already healthy individual.

A parish nurse for a Catholic church provides a free blood pressure screening the first Sunday of every month. This is what level of prevention? A) Tertiary prevention B) Primary prevention C) Secondary prevention D) Quaternary prevention

B. Primary prevention Primary prevention is true prevention that precedes disease and is aimed at clients considered physically and emotionally healthy. Secondary prevention involves individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce negative impacts and complications. Quaternary prevention is not a recognized term.

The nurse's main priority when caring for a patient with hemiplegia? A. Educating the patient B. Providing a safe environment C. Promoting a positive self-image D. Helping the patient accept the illness

B. Providing a safe environment A patient with hemiplegia (paralysis of one side of the body) has a high risk of injury because of his altered motor and sensory function, so safety is the nurse's main priority.

After establishing a nursing diagnosis of Acute pain, the nurse develops which of the following appropriate client-centered goals? A) Determine effect of pain intensity on client function. B) Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay. C) Encourage client to implement guided imagery when pain begins. D) Administer analgesic 30 minutes before physical therapy treatment.

B. Reduce pain intensity to the level of a client rating of 3 or below during the client's hopsital stay

A nurse provides counseling to a family in spiritual distress caused by the recent, but expected, death of a family member when the nurse implements which of the following interventions? A) Praying with the family B) Reminiscing with the family C) Arranging for the chaplain to visit the family D) Obtaining a consult with a psychiatric clinical nurse specialist

B. Reminiscing with the family Reminiscing is an active intervention that allows family members to remember the deceased in a positive way. One expects spiritual distress in the acute stage of loss. Praying with the family and arranging for a chaplain's visit may be appropriate interventions, but they are not counseling.

A client who is alert and responsive was admitted directly from the physician's office with a diagnosis of "rule out acute myocardial infarction." Of the following alterations found on the initial assessment, which is of greatest concern to the nurse? A. Blood pressure supine is 138/76 B. Respirations are 28 and labored C. Temperature is 99.8 F D. There are infrequent missed apical beats

B. Respirations are 28 and labored Using the principles of the ABCs (airway, breathing, and circulation), an alteration in respiration is always a primary concern. A disturbance in normal ventilation (rate 16-20) is occurring secondary to the medical diagnosis of myocardial infarction. The blood pressure remains in acceptable range, and the slight temperature elevation is likely related to the overall inflammatory response of the body. Infrequent abnormalities of cardiac rhythm are common and should be of concern when appearing frequently or with longer duration.

The nurse is teaching a parenting class for a group of pregnant adolescents and has given the adolescents baby dolls to bathe and talk to. This is an example of: A) An analogy B) Role playing C) A demonstration D) A return demonstration

B. Role playing Role playing involves rehearsing a desired behavior. In demonstration the nurse shows the client what to do, whereas in return demonstration the learner practices the skill to show that it has been learned. An analogy is a means of translating complex language or ideas into words or concepts that the client understands.

Newborn screening is done to every newborn in the Philippines. This is an example of: A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Rehabilitation

B. Secondary prevention Promotion of early detection and early treatment of the disease is under secondary prevention. Example, breast self exam, TB screening, genetic counseling.

When teaching is viewed as communication, then a specific learning objective can be said to be developed from: A) The message B) The referent C) Feedback D) Intrapersonal variables

B. The referent The referent is the perceived need for information. This provides the basis for the learning objective. The message refers to the information taught. Feedback is used to determine whether or not the learning objective was achieved. Intrapersonal variables are assessed to determine willingness and ability to learn.

The nurse should plan to teach a client about the importance of exercise: A) When there are visitors in the room B) When the client's pain medications have taken effect C) Just before lunch, when the client is most awake and alert D) When the client is talking about current stressors in his or her life

B. When the client's pain medications have taken effect It is difficult for a client to learn when the client is in pain. Pain medications should be administered and the client taught while the client is alert but pain free. A quiet time should be selected when there are no or few distractions; the nurse should avoid times when visitors are present or when the client is discussing other stressors. The second best time to teach is when the client is most awake and alert, providing that all pain issues have been addressed.

The urine appears concentrated and cloudy because of the presence of white blood cells or __________________________.

Bacteria

Which of the following are important adverse effects of nonsteroidal antiinflammatory drugs (NSAIDs) for which the nurse continually assesses older adult clients receiving long-term NSAID therapy? (Select all that apply.) A) Diarrhea B) Liver failure C) Renal insufficiency D) Gastrointestinal (GI) bleeding

C and D Renal insufficiency and GI bleeding are frequent adverse effects of long-term NSAID use in older clients. The normal aging process results in decreased renal function, and the addition of NSAIDs may accelerate this process. NSAIDs are common over-the-counter drugs, and as a result, clients may believe these drugs are safe in high dosages. Liver failure can occur with consumption of acetaminophen. Diarrhea is not usually an adverse effect of NSAID use.

A client's family member wipes her eyes as she cries at the loss of a loved one and says, "It's no big deal. I mean, we all have to die sometime, right?" The nurse is engaging in metacommunication when the nurse responds: A) "You are taking this really well." B) "You are exactly right. Dying is inevitable." C) "Losing a loved one can be really difficult. It looks like you're pretty upset. I'd like to help." D) "Let's not talk about it. That will help you feel better. After all, God won't give you more than you can handle."

C) "Losing a loved one can be really difficult. It looks like you're pretty upset. I'd like to help." Metacommunication uncovers the deeper message beneath what is being overtly said. Option 3 would be the most therapeutic response by the nurse. In options 1 and 2, the nurse is not attending to the nonverbal cues in these responses but sounds oblivious to the real feelings being expressed by the family member. The nurse should allow the client to verbalize those feelings.

Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching? A) "I won't put the baby to bed with a bottle." B) "For the first few weeks, we are putting the cradle in our room." C) "My grandmother told me that babies sleep better on their stomachs." D) "I know I will have to get up during the night to feed the baby when he wakes up."

C) "My grandmother told me that babies sleep Babies should sleep on their backs, not their stomachs, as a SIDS preventative. Babies should not be put to bed with a bottle. Due to nighttime feedings, new moms should be encouraged to temporarily place a cradle near where they sleep and know that they will have to get up during the night to feed the baby.

The nurse is caring for a client who has undergone cardiac catheterization. The client says to the nurse, "The doctor said my cardiac output was 5.5 L/min. What is normal cardiac output?" Which of the following is the nurse's best response? A) "It is best to ask your doctor." B) "Did the test make you feel upset?" C) "The normal cardiac output for an adult is 4 to 6 L/min." D) "Are you able to explain why are you asking this question?"

C) "The normal cardiac output for an adult is 4 to 6 L/min." The client asked a direct question that the nurse should be able to answer. Normal cardiac output for an adult is 4 to 6 L/min. Questions regarding diagnosis and prognosis may be referred to physicians. There is no harm in answering this question. When using therapeutic communication, the nurse should never ask a client to justify his or her feelings by inquiring why a question was asked. There is no evidence that this client is upset

The clients most in need of perineal care are those at greatest risk of: A) Dying B) Falling C) Acquiring an infection D) Needing to be institutionalized

C) Acquiring an infection Absence of perineal care can put a client at risk for an infection. Those at greatest risk of infection should receive appropriate perineal care. The other options involve populations that are also at risk for infections.

If the nurse is working with a client who has expressive aphasia, it would be most helpful for the nurse to: A) Ask open-ended questions. B) Speak loudly and use simple sentences. C) Allow extra time for the client to respond. D) Encourage a family member to answer for the client.

C) Allow extra time for the client to respond. For clients with aphasia, the nurse should be sure to allow extra time for the client to respond. Asking open-ended questions is important, but these questions need to be developed based on the client's personal communication ability. Speaking loudly is not necessary for a client with a diagnosis of aphasia. The client should be encouraged to answer questions himself or herself and not expect others to answer for the client, even if it takes longer for the client to do so.

In assessing a 55-year-old client who is in the clinic for a routine physical, the nurse instructs the client about the need to provide a stool specimen for guaiac fecal occult blood testing: A) If the client notices rectal bleeding B) If there is a family history of intestinal polyps C) As part of a routine screening for colon cancer D) If a palpable mass is detected on digital examination

C) As part of a routine screening for colon cancer Routine screening for colon cancer includes fecal occult blood testing. There does not need to be a reason for routine screening, such as a family history, masses, or bleeding, although these can indicate the need for further testing.

When setting goals for a client with chronic pain, the nurse should begin by doing which of the following? A) Identifying the cause of the pain B) Asking "What pain rating is acceptable to your family?" C) Asking "What does your pain prevent you from doing that you used to do?" D) Getting an idea of what pain intensity will allow the client to perform the activities of daily living (ADLs)

C) Asking "What does your pain prevent you from doing that you used to do?" Understanding what the pain prevents the client from doing that is important helps in establishing a goal that the nurse can measure. This also assists in identifying what is important to the client. A pain rating that is acceptable to the client is more important than one that is acceptable to family members. An acceptable pain rating is unique and individual to the client. Clients may perform ADLs even though they are in pain because ADLs are often necessary for survival. Although identifying the cause of pain is important, it is not essential in establishing goals.

The nurse demonstrates active listening by: A) Agreeing with the client B) Repeating everything the client says to clarify C) Assuming a relaxed posture and leaning toward the client D) Smiling and nodding continuously throughout the interview

C) Assuming a relaxed posture and leaning toward the client Active listening means being attentive to what the client is saying both verbally and nonverbally. Assuming a relaxed posture and leaning toward the client facilitates listening. Agreeing with the client does not facilitate communication. Repeating everything the client says can become distracting. Smiling and nodding continuously is not responding to what the client says at all times.

A nurse should consider zones of personal space and touch when caring for clients. If the nurse is taking the client's nursing history, she should: A) Sit next to the client B) Be 4 to 12 feet from the client C) Be 18 inches to 4 feet from the client D) Be 12 inches to 3 feet from the client

C) Be 18 inches to 4 feet from the client The personal zone is 18 inches to 4 feet and is best when the nurse is taking a client's history. The intimate zone is 0 to 18 inches, and the nurse is in this zone when performing assessment. The social zone is 9 to 12 feet and is used when making rounds with a physician. The public zone is 12 feet or more.

Which of the following medications are the safest to administer to adults needing assistance in falling asleep? A) Sedatives B) Hypnotics C) Benzodiazepines D) Antianxiety agents

C) Benzodiazepines The safest group of drugs is the benzodiazepenes. They facilitate the action of the neurons in the central nervous system (CNS) that suppress responsiveness to stimulation, therefore decreasing levels of arousal. The other medications can be used, but long-term use of antianxiety, sedative, or hypnotic agents can disrupt sleep and lead to more serious problems.

Fever increases the tissues' need for oxygen, and as a result: A) Metabolic demands decrease B) Blood glucose stores stabilize C) Carbon dioxide production increases D) Carbon dioxide production decreases

C) Carbon dioxide production increases Fever increases the tissues' need for oxygen, and as a result, carbon dioxide production increases. When fever persists, the metabolic rate remains high and the body begins to break down protein stores, which results in muscle wasting and decreased muscle mass.

12. For which airborne disease(s) would the nurse be required to use gloves, respiratory devices, and gown when in close contact with the client? A) Herpes simplex, scabies B) Viral pneumonia, atelectasis C) Chickenpox, pulmonary tuberculosis D) Multidrug-resistant respiratory syncytial virus

C) Chickenpox, pulmonary tuberculosis Airborne precautions are required for chickenpox and tuberculosis, because in these diseases small particles float in the air and a barrier is required to prevent contamination of the nurse. A respiratory protection device is form-fitted to the face to prevent the escape of air around the seal. Gloves and gown are also worn to prevent contamination and transport of infective particles to other clients. For viral pneumonia a regular mask is used as a barrier because the particles do not float in the air and are more likely to be found on surfaces unless coughing or spitting is occurring. Atelectasis is the collapse of alveoli, and airborne precautions are not needed. Herpes and scabies are spread by contact, and gloves and gown would be necessary; masks would not be needed. For multidrug-resistant respiratory syncytial virus the protection of the client would be as important as preventing the spread of these disorders. Therefore, gown, gloves, and mask would be used as in reverse isolation to prevent cross contamination of the client.

The results of many diagnostic tests performed to identify the cause of a client's chronic low back pain come back negative. This indicates to the physician and nurse that the client's pain is: A) Psychological B) Overestimated C) Currently idiopathic D) Caused by low pain tolerance

C) Currently idiopathic The fact that a cause for pain cannot be identified through laboratory or diagnostic tests does not mean that the pain is not real. It may indicate that the current tests are not sophisticated enough to detect the abnormality.

During the nurse's assessment of a 56-year-old man, he reports increased alcohol consumption because of stress at work. One of the expected outcomes for this client will be to: A) Decrease stress in his life. B) Teach him ways to promote sleep. C) Decrease his alcohol intake during times of stress. D) Provide the client with information about stress management classes.

C) Decrease his alcohol intake during times of stress. Resources for stress management and sleep promotion can help accomplish reduced alcohol intake during times of stress in the client's life. Management of stress is the expectation, but decreasing stress may not be possible.

The nurse is caring for a client with a chest tube in the right thorax. On first assessment the nurse notes that there is bubbling in the water-seal chamber. This client is scheduled to undergo a chest x-ray examination, and the transporters have arrived to take him by wheelchair to the radiology department. The nurse considers whether the chest tube should be clamped or not during the trip to the radiology department. The nurse makes the which correct decision? A) Clamp the chest tube, but vent the system to air. B) Clamp the chest tube and disconnect it from the wall suction. C) Do not clamp the chest tube and disconnect it from the wall suction. D) Do not clamp the chest tube and connect it to temporary intermittent suction.

C) Do not clamp the chest tube and disconnect it from the wall suction. A bubbling chest tube (in the water-seal portion) should never be clamped because it provides the only exit for air accumulating in the pleural space. If the tube is clamped, tension pneumothorax could occur, which could be fatal. There is no advantage to clamping the chest tube but venting the system. Clamping of the chest tube prevents communication of the chest tube with the venting system or with the wall suction. There is no such thing as "temporary suction" for a chest tube system.

The nurse recognizes that the organism that most frequently causes urinary tract infections (UTIs) in women is: A) Aspergillus B) Streptococcus C) Escherichia coli D) Staphylococcus aureus

C) Escherichia coli Because the female urethra is positioned close to the anus, most UTIs are a result of contamination of the urethra with organisms from the gastrointestinal (GI) tract. The organisms in options 1, 2, and 4 are not normally found in the GI tract and thus are not commonly associated with UTIs.

The nurse discovers an electrical fire in a client's room. The nurse's first action would be to: A) Activate the fire alarm. B) Confine the fire by closing all doors and windows. C) Evacuate any clients or visitors in immediate danger. D) Extinguish the fire by using the nearest fire extinguisher.

C) Evacuate any clients or visitors in immediate danger. The nurse's first step when a fire is discovered is to evacuate any clients or visitors in immediate danger. Then the nurse should activate the fire alarm, confine the fire, and then extinguish it.

To minimize nocturia, clients should avoid fluids: A) After lunch B) In the late afternoon C) For 2 hours before bedtime D) For 4 hours before bedtime

C) For 2 hours before bedtime Clients should avoid fluids for 2 hours before bedtime to prevent nocturia. The other options will not prevent nocturia.

Before the nurse washes the hands when leaving an isolation room, what is the last thing that is removed? A) Mask B) Gown C) Goggles D) Head cover

C) Goggles Goggles are the least contaminated item and the last to be removed before hand washing. The gown and gloves have been removed first. Head covers are usually not worn in isolation rooms as a barrier. The mask is considered contaminated, and it should be untied and discarded after the gown is removed to minimize contamination from the gown or gloves.

To remove a glove that is contaminated, what should the nurse do first? A) Rinse the glove before removing it to minimize contamination. B) Pull the glove off the back of the hand until it slides off the entire hand and discard it. C) Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching the wrist or fingers. D) Put the thumb inside the wrist to slide the glove over the hand with minimal touching of the hand by the other gloved hand.

C) Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching the wrist or fingers. When the outside of the cuff is grasped with the contaminated gloved hand, then dirty to dirty remains intact. Pulling the glove away from the hand entirely without touching the wrist or fingers further minimizes the contamination by the gloved hand. If the nurse puts the gloved thumb inside the glove, the nurse has contaminated the bare hand with a contaminated thumb. Pulling the glove off by holding it at the back sounds good and could minimize contamination, but it is very difficulty to remove a glove this way without the risk of tearing the glove and creating contamination through the tear. If excessive secretions are present on gloves, then a towel or the drape could be used to wipe off excessive secretions before an attempt is made to remove the gloves.

The nurse understands that providing a complete bed bath may have which of the following cardiovascular effects and thus plans for rest periods during the bath? A) Increase in oxygen supply B) Decrease in glucose demand C) Increase in oxygen consumption D) Decrease in blood supply to the skin

C) Increase in oxygen consumption Turning during a complete bed bath and receiving back care increases oxygen demand and consumption. Thus it is important for the nurse to provide rest periods and monitor heart rate before, during, and after the bath. Blood flow to the skin should increase with gentle rubbing from the bath. Glucose demand should increase as a result of increased activity. Oxygen supply is not increased with a complete bed bath, but oxygen demand does increase.

During the nursing assessment the client reveals that he has diarrhea and cramping every time he eats ice cream. He attributes this to the cold temperature of the food. However, the nurse begins to suspect that these symptoms might be associated with: A) Food allergy B) Irritable bowel C) Lactose intolerance D) Increased peristalsis

C) Lactose intolerance Lactose intolerance occurs in individuals who lack the enzyme needed to digest the milk sugar lactose. Diarrhea and cramping following dietary ingestion are signs of lactose intolerance. This is the most specific answer.

A client with head and neck cancer has begun receiving radiation therapy to the right side of the neck. Because of the radiation treatments, the nurse includes which of the following interventions in the client's plan of care? A) Gargling with mouthwash every 8 hours B) Lemon glycerin swabs to the mouth every 2 hours C) Mouth care every 4 hours with a nondrying mouthwash D) Nothing by mouth (NPO) status during radiation therapy treatments

C) Mouth care every 4 hours with a nondrying mouthwash Radiation therapy to the head and neck can impair the secretion of saliva. Routine and frequent mouth care is essential. The nurse does not want to use mouth care products that contribute to further drying of the mucous membranes of the mouth. There is no reason that clients must remain NPO during radiation therapy. In fact, offering fluids is important during this time to assist in hydrating the mucous membranes. The products in options 1 and 2 are very drying and irritating to the mucous membranes of the mouth and should be avoided.

14. The nurse is setting up a sterile field for the physician. Which of the following statements concerning a sterile field is correct? A) The sides of the drape over the table are still sterile until they are touched. B) Reaching over the field is not a source of contamination if the nurse has on a clean gown and gloves. C) One inch around the border should be considered to be the barrier between the sterile field and under the table. D) A liquid spill onto the sterile field is a source of contamination from the table below the drape, even if the barrier is waterproof.

C) One inch around the border should be considered to be the barrier between the sterile field and under the table. A 1-inch margin is considered unsterile and is the barrier spacing between the sterile field in the center of the drape and the edge of the drape. Liquids spilled on a waterproof drape will not absorb from or be contaminated from the surface beneath. Although such a situation could be messy, bacteria would not cross from the unsterile to the sterile side. The edge of the table and the 1-inch border create the edge of the sterile field. Anything below the edge, including the side of the drape, becomes unsterile. Reaching over a sterile field is always a source of contamination and should not be done.

To validate the suspicion that a married male client has sleep apnea, the nurse first: A) Schedules the client for a sleep test. B) Asks the client if he experiences apnea in the middle of the night. C) Questions the spouse if she is awakened by her husband's snoring. D) Places the client on a continuous positive airway pressure (CPAP) device.

C) Questions the spouse if she is awakened by her husband's snoring. Asking the spouse would be a starting place to determine if a client has sleep apnea. This may lead to determining whether more tests are needed. The client would not know if he experiences sleep apnea. CPAP is a treatment for sleep apnea. Although this is a diagnostic tool, the first thing the nurse would do is question the spouse.

The nurse is concerned when a client's heart rate, which is normally 95 beats per minute, rises to 220 beats per minute, because a rate this high will: A) Exhaust the client B) Decrease metabolic rate C) Reduce coronary artery perfusion D) Provide too much blood flow to major organs

C) Reduce coronary artery perfusion Coronary arteries fill and perfuse the myocardium (heart muscle) during diastole. When the heart rate is elevated, more time is spent in systole and less in diastole; hence, the myocardium may not be perfused adequately. The client may be exhausted, but the primary concern is myocardial perfusion. Major organs will adjust to increased blood flow. This is usually not a problem. With a heart rate this high, metabolic rate will be increased, not decreased.

client underwent total knee replacement and was placed on patient-controlled analgesia (PCA). The client has been activating the drug button an average of 4 times per hour. The nurse has assisted the client on and off the bedpan 2 or 3 times an hour for the past 2 hours. Urine output was about 50 ml with each void. The nurse now begins to suspect: A) Fluid overload B) Urge incontinence C) Retention overflow D) Urinary tract infection (UTI)

C) Retention overflow Urinary retention may cause increased pressure in the bladder to the point that the external urethral sphincter is unable to hold back urine. The sphincter temporarily opens to allow a small volume of urine to escape. Bladder pressure then falls, and the sphincter closes again. The nurse should also assess the lower abdomen for bladder distention. The symptom described does not justify the selection of the other options. There is no sense of urgency. Fluid overload would more likely present as lung congestion. A UTI would have additional symptoms.

The nurse is about to insert a urinary catheter into an uncircumcised client. After retracting the foreskin and inserting and securing the catheter, the nurse must be sure to: A) Secure the catheter to the client's leg. B) Clean the urinary meatus with povidone-iodine. C) Return the foreskin over the glans penis. D) Culture the first urine to drain into the collection bag.

C) Return the foreskin over the glans penis. If the nurse does not pull the foreskin back over the glans penis, it could act as a tourniquet. The glans penis could become extremely swollen and require an emergency circumcision. The insertion of the urinary catheter already required cleansing of the meatus. Securing the catheter to the leg or to the abdomen is important, but it is not essential. Cultures are not performed on urine that has drained into the collection bag.

A nursing instructor notices that a student nurse is showing a lack of professionalism when the student: A) Accepts responsibility for an error he made in documentation B) Arrives on time and is clean and neat, wearing no perfume or cologne C) Shares personal information about his assigned client with other students not involved in the client's care D) Knocks on the door before entering and says, "Hello, Mr. Smith. I am Bill Johnson, and I'll be your student nurse today."

C) Shares personal information about his assigned client with other students not involved in the client's care Sharing personal information about others violates nursing ethical codes and practice standards. Team members directly involved in the client's care should be given only relevant information about the client's status. To practice courtesy, the nurse knocks on doors before entering and uses self-introduction. A professional is expected to be clean, neat, well groomed, conservatively dressed, and scent and odor free. Being on time, organized, well prepared, and equipped for the responsibilities of the nursing role also communicate one's professionalism. Professional nurses make choices and accept responsibility for the outcome of their actions.

During the enema the client begins to complain of pain. The nurse notes blood in the return fluid and rectal bleeding. The nurse's next action is to: A) Stop the instillation. B) Slow down the rate of instillation. C) Stop the instillation and measure vital signs. D) Tell the client to breathe slowly and relax

C) Stop the instillation and measure vital signs. If bleeding occurs on enema administration, the nurse should stop the infusion, measure vital signs, and notify the health care provider.

A client is receiving oxygen via a nonrebreathing mask. A crucial nursing assessment the nurse performs is to be sure that: A) The oxygen flow meter is set at 2 L/min. B) The mask is connected to a heating element. C) The bag attached to the mask is inflated at all times. D) The straps securing the mask are not causing skin ulcers over the top of the ears.

C) The bag attached to the mask is inflated at all times. If the bag attached to a nonrebreathing mask is deflated, the client is at risk for breathing in large amounts of exhaled carbon dioxide. The bag should be maximally inflated at all times. Checking the straps to make sure they are not causing skin ulcers is important but not crucial. For a nonrebreathing mask 2 L/min is far too low a flow setting. The oxygen flow should be set at 10 L/min or more. Otherwise, the bag will collapse. Heating the fluid used to increase humidity is not essential.

An intern new to the service writes an order for OxyContin SR 10 mg by mouth every 12 hours as needed. Which part of the order does the nurse question? A) The dose B) The drug C) The time interval D) The route

C) The time interval OxyContin SR is a long-acting opioid that requires regular dosing to be effective. This medication should be prescribed for regular use and a short-acting medication provided for as-needed dosing for breakthrough pain. The rest of the elements in the drug order are correct.

11. The nurse may facilitate verbal communication with clients by: A) Using words that can have several meanings B) Using medical terminology to ensure accuracy C) Using short sentences that express an idea simply and directly D) Speaking slowly and deliberately and allowing long pauses in the conversation

C) Using short sentences that express an idea simply and directly Verbal communication should be clear and brief. Fewer words result in less confusion. Communication that is simple, brief, and direct is more effective. Medical jargon may sound like a foreign language to clients unfamiliar with the health care setting and should be used only with other health team members. Nurses should carefully select words that cannot be easily misinterpreted, especially when explaining a client's medical condition or therapy. Speaking slowly and deliberately can convey an unintended message. Long pauses and rapid shifts to another subject may give the impression that the nurse is hiding the truth.

What is the single most effective method by which the nurse can break the chain of infection? A) Give all clients antibiotics. B) Wear gloves when caring for all clients. C) Wash hands between procedures and clients. D) Make sure housekeeping staff are using the right chemicals.

C) Wash hands between procedures and clients. Adequate hand washing will remove bacteria and wastes or contaminates to minimize cross contamination between clients. Use of alcohol-based waterless antiseptics between clients is also effective if the guidelines for using these cleansers are followed. Giving all clients antibiotics is impractical and is a source of new superinfections when persons who do not need antibiotics are given them and then the bacteria mutate to become resistant to older drugs. It would be both unethical and costly to try to control infections by treating everyone in the facility. Although wearing gloves to perform procedures that carry the risk of direct contact with contaminated material is a correct method of bacterial control, wearing gloves at all times is impractical, expensive, and unrealistic. Housekeeping staff are trained to use the correct agents for decontamination and disinfection of all surfaces that place clients at risk.

Elimination changes that result from obstruction to the flow of urine in the urinary collecting system may cause which of the following? (Select all that apply.) A) Blood clots B) Dehydration C) Renal damage D) Urinary retention E) Urinary tract infection

C, D, and E Obstruction can cause renal damage, urinary retention, and urinary tract infections.

During the planning phase of the nursing process, the nurse along with the client decides which of the following? (Select all that apply.) A) Interventions B) Nursing diagnosis C) Expected outcomes D) Client-centered goals E) Nurse-centered priorities

C, and D Expected outcomes and goals are the main components of the planning phase of the nursing process. The nurse determines these from the assessment. The client should be the focus of the planning stage. Interventions are initially determined by the nurse.

3. Based on the transtheoretical model of change, what is the most appropriate response to the following client statement: "Me, exercise? I haven't done that since Junior High gym class and I hated it then!" A) "That's fine. Exercise is bad for you anyway." B) "OK. I want you to walk 3 miles four times a week and I'll see you in 1 month." C) "I understand. Can you think of one reason why being more active would be helpful for you?" D) "I'd like you to ride your bike three times this week and eat at least four fruits and vegetables every day."

C. "I understand. Can you think of one reason why being mroe active would be helpful for you?" The transtheoretical model of change describes a series of changes that clients move through, starting with precontemplation and ending with maintenance. The first stage for this client would be to validate the client's opinion and move to the first part of precontemplation. The other options are later steps in the model.

Which of the following statements is the World Health Organization's definition of health? A) "Complete freedom from disease" B) "Mental, social, and spiritual well-being" C) "State of complete physical, mental, and social well-being, not merely the absence of disease" D) "A state of being that people define in relation to their own values, personality, and lifestyle"

C. "State of complete physical, mental, and social well-being, not merely the absence of disease" The World Health Organization defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." There are several definitions of health. Health is a state of being that people define in relation to their own values, personality, and lifestyle. Health and illness must be defined in terms of the individual. Health can include conditions previously considered to be illness. Pender, Murdaugh, and Parsons note that views of health include mental, social, and spiritual well-being. Pender notes that not all people who are free of disease are equally healthy.

Which of the following is an open-ended question the nurse might use when interviewing a client? A) "Do you have any concerns right now?" B) "Is your family worried about your being in the hospital?" C) "What do you mean when you say, 'I don't feel quite right'?" D) "How many times do you get up to go to the bathroom at night?"

C. "What do you mean when you say, 'I don't feel quite right'?" The way the nurse asks question 3 allows the client to respond completely and with more than a one-word answer. The other options allow the client to respond with one word and make it unlikely that the client will give additional information.

The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she gets up at night. She replies, "Yes." What other question should the nurse ask? A) "How many times do you get up at night?" B) "How long have you been getting up at night?" C) "Why do you get up at night?" D) "How easily do you go back to sleep after you get up?"

C. "Why do you get up at night?" Perhaps it is the client's husband who is getting up in the middle of the night because of a prostate problem, and this is why she is awakened. The nurse should not assume nocturia without further assessment questions.

To assess the adequacy of food intake, which of the following assessment parameters is best used? A. Food preferences B. Regularity of meal times C. 3-day diet recall D. Eating style and habits

C. 3-day diet recall 3-day diet recall is an example of dietary history. This is used to indicate the adequacy of food intake of the client.

nursing diagnosis is: A) The diagnosis and treatment of human responses to health and illness B) The advancement of the development, testing, and refinement of a common nursing language C) A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes D) The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests

C. A clinical judgment about individual, family, or community responses toa ctual and potential health problems or life processes A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. It is not a disease condition or medical diagnosis, or the diagnosis and treatment of human responses to health and illness. Nursing diagnoses are not a development or refinement in nursing language.

Maslow's hierarchy of needs is useful to nurses, who must continually prioritize a client's nursing care needs. The most basic or first-level needs include: A) Self-actualization B) Love and belonging C) Air, water, and food D) Esteem and self-esteem

C. Air, water, and food The first level of Maslow's hierarchy of needs includes the need for air, food, and water—basic elements of survival. Love and belonging are on the second level, esteem and self-esteem are on the fourth level, and self-actualization is the final level.

It is the gradual decrease of the body's temperature after death: A. Livor mortis B. Rigor mortis C. Algor mortis D. none of the above

C. Algor mortis Algor mortis is the decrease of the body's temperature after death. Livor mortis is the discoloration of the skin after death. Rigor mortis is the stiffening of the body that occurs about 2-4 hours after death.

What is the order of the nursing process? A. Assessing, diagnosing, implementing, evaluating, planning B. Diagnosing, assessing, planning, implementing, evaluating C. Assessing, diagnosing, planning, implementing, evaluating D. Planning, evaluating, diagnosing, assessing, implementing

C. Assessing, diagnosing, planning, implementing, evaluating The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.

A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of: A. Planning B. Evaluation C. Assessment D. Intervention

C. Assessment Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is analyzed for problem resolution. Intervention consists of the steps actually taken after planning. Evaluation measures the effectiveness of the plan.

A nurse uses an institution's procedure manual to confirm how to insert a Foley catheter. The level of critical thinking the nurse is using is: A. Commitment B. Scientific method C. Basic critical thinking D. Complex critical thinking

C. Basic critical thinking At the basic level of critical thinking, a learner trusts the experts and follows a procedure step by step. Complex critical thinkers separate themselves from authorities and analyze and examine choices more independently. Commitment is the third level of critical thinking in which the person anticipates the need to make choices without assistance from others. The scientific method is a process of problem solving.

Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia? A. Oriented to date, time and place B. Clear breath sounds C. Capillary refill greater than 3 seconds and buccal cyanosis D. Hemoglobin of 13 g/dl

C. Capillary refill greater than 3 seconds and buccal cyanosis Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data.

During the nursing rounds Nurse Cathy is instructing the patient to avoid smoking to prevent the worsening of respiratory problems. The patient asked about the things that he can do when feelings of wanting to smoke arises. The nurse enumerates ways of dealing the situation. This is an example of a nurse's role as a/an: A. Advocate B. Clinician C. Change agent D. Caregiver

C. Change agent As a change agent, the nurse assists the client to MODIFY their BEHAVIOR. As an advocate the nurse intercedes or works on behalf of the client. As a clinician, the nurse would use technical expertise to administer nursing care. The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness by viewing a person holistically.

What type of interview technique is the nurse using when the nurse asks the question, "Do you have pain or cramping?" A) Active listening B) Open-ended questioning C) Closed-ended questioning D) Problem-oriented questioning

C. Closed-ended question The example is a closed-ended question which the client can answer with a one-word reply. Open-ended questions allow the client to answer with more information. The other options are not correct.

The client is a 65-year-old overweight woman with multiple medical diagnoses, including diabetes mellitus type 2, hypertension, and residual right-sided weakness resulting from a previous cerebrovascular accident. What tool should be used to plan her care? A) Care plan B) Care map C) Concept map D) Critical thinking

C. Concept map A concept map is a visual representation of client problems and interventions that shows their relationships to each other and allows easy synthesis of data about the client.

In order to examine the ocular mobility of a client who recently experienced a stroke, the nurse should examine which of the following cranial nerves? Select all that apply. A. Cranial Nerves I and VII B. Cranial Nerves II and V C. Cranial Nerves III and IV D. Cranial Nerve VI E. Cranial Nerve IX

C. Cranial Nerves III and IV D. Cranial Nerve VI Evaluation of ocular motility provides information about the extra ocular muscles; the orbit; cranial nerves III, IV, and VI; their brain stem connections; and the cerebral cortex. Cranial nerves I, VII, and IX, respectively, assess smell, facial movement, swallowing, and the tongue.

Constipation is a common problem for immobilized patients because of: A. Decreased tightening of the anal sphincter B. An increased defecation reflex C. Decreased peristalsis and positional discomfort D. Increased colon motility

C. Decreased peristalsis and positional discomfort Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility and more tightly constricted sphincters.

A learning objective for a client taking digoxin (Lanoxin) is to correctly take a radial pulse for 1 minute before medication administration. The learning objective has been achieved when the client: A) States, "I understand." B) States, "Just place two fingers at the thumb side of the wrist." C) Demonstrates correct finger placement and counts the beats correctly D) Demonstrates by placing two fingers at the inner antecubital space and counts the beats for 60 seconds

C. Demonstrates correct finger placement and counts the beats correctly Direct observation is a means of evaluating whether a learning objective has been achieved. In option 3 the client demonstrated radial pulse taking correctly. Option 1 provides no way of measuring if the client was able to correctly take a radial pulse. Option 2 does not indicate if the client was able to count the number of beats for 1 minute. In option 4 the fingers were placed in the antecubital space rather than over the radial artery. The client demonstrated incorrect placement.

A client who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. The best teaching method would be: A) Role playing B) Simulation C) Demonstration D) Group instruction

C. Demonstration Demonstration with return demonstration is the best method to teach a psychomotor skill. Group instruction is not typically effective in teaching specific psychomotor skills, because it does not allow for individualized instruction. Role playing and simulation are not appropriate in this situation.

Each science has a domain, which is the perspective of the discipline. This domain: A) Represents the recipients of the benefits of the science or discipline B) Is a model that explains the linkage of science, philosophy, and theory that is accepted and applied by the discipline C) Describes the subject, central concepts, values and beliefs, phenomena of interest, and central problems of the discipline D) Is a dynamic state of being in which the developmental and behavioral potential of the individual is realized to the fullest

C. Describes the subject, central concepts, values and beliefs, phenomena of interest, and central problems of the discipline The domain contains the subject, central concepts, values and beliefs, phenomena of interest, and the central problems of the discipline. A paradigm is a model that explains the linkage of science, philosophy and theory that is accepted and applied by the discipline.

The school nurse is about to teach a freshman-level health class on nutrition. To achieve the best learning outcomes, the nurse: A) Provides information using a lecture format B) Uses simple words to promote understanding C) Develops topics for discussion that require problem solving D) Completes an extensive literature search focusing on eating disorders

C. Develops topics for discussion that require problem solving The use of problem solving helps adolescents to achieve learning outcomes. Providing information in a lecture format and using simple words would probably not be successful with this age group. Literature searches are not appropriate teaching for this age group.

"Unhappy and worried about health" is not a scientifically-based nursing diagnosis, and it can lead to error in: A) Data collection B) Date clustering C) Diagnostic label D) Medical diagnosis

C. Diagnostic label The diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association (NANDA) International. The question does not discuss data collection, medical diagnosis, or data clustering.

Which of the following nursing interventions is written correctly? A) Change dressing once a shift. B) Perform neurovascular checks. C) Elevate head of bed 30 degrees before meals. D) Apply continuous passive motion machine during day.

C. Elevate head of bed 30 degrees before meals Option 3 is specific—it indicates what to do and when

A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action? A. Administer a sedative at bedtime, as ordered by the physician B. Ambulate the patient for 5 minutes before he retires C. Give the patient a glass of warm milk before bedtime D. Close the patient's door from 9pm to 7am

C. Give the patient a glass of warm milk before bedtime Warm milk will relax the patient because it contains tryptophan, a natural sedative.

17. The nursing process is an example of an open system. An open system: A) Is universal and dynamic B) Represents a relationship between two concepts C) Interacts with the environment by exchanging information D) Is a process through which information is returned to the system

C. Interacts with the environment by exchanging information An open system is defined as a system that interacts with the environment, exchanging information between the system and the environment.

The nurse asks a client how she feels about impending surgery for breast cancer. Before initiating the discussion the nurse reviewed information about loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurse's review of the literature is: A) Experience B) Problem solving C) Knowledge application D) Clinical decision making

C. Knowledge application The nurse sought appropriate information to be able to communicate more knowledgeably with the client. Experience is acquired through clinical learning situations. Problem solving is a series of steps to resolve a problem. Clinical decision making is a process in which critical thinking steps are followed for problem resolution.

In which position should the nurse place the client to best inspect and palpate the Bartholin glands? A. Semi-Fowler's B. Sim's C. Lithotomy D. Prone

C. Lithotomy The Bartholin glands are part of the female anatomy located on the posterior aspect of the vaginal orifice. Therefore, if the medical condition allows, having the client in a lithotomy position (on her back, knees flexed, legs apart, with feet supported on a surface or in stirrups) will provide the best opportunity for examination. The other responses do not allow for assessment of the female genitalia.

Which of the following is the most important purpose of planning care with a patient? A. Development of a standardized NCP. B. Expansion of the current taxonomy of nursing diagnosis C. Making of individualized patient care D. Incorporation of both nursing and medical diagnoses in patient care

C. Making of individualized patient care To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient.

Prolonged deficiency of Vitamin B9 leads to: A. Scurvy B. Pellagra C. Megaloblastic anemia D. Pernicious anemia

C. Megaloblastic Prolonged Vitamin B9 deficiency will lead to megaloblastic anemia while pernicious anemia results in deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads to scurvy and Pellagra results in deficiency in Vitamin B3.

During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient? A. That the patient verbalized, "My headache is gone." B. That the patient's barium enema performed 3 days ago was negative C. Patient's NGT was removed 2 hours ago D. Patient's family came for a visit this morning.

C. Patient's NGT was removed 2 hours ago The change-of-shift report should indicate significant recent changes in the patient's condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report

Which of the following models of health or illness defines health as a positive, dynamic state, not merely the absence of disease? A) Maslow's hierarchy of needs B) Rosenstoch's health belief model C) Pender's health promotion model D) The holistic health model of nursing

C. Pender's health promotion model Pender's health promotion model was developed to be a "complementary counterpart to models of health protection." This model defines health as a positive, dynamic state, not merely the absence of disease. Maslow's hierarchy of needs defines what is necessary for human survival and health, such as food, water, safety, and love. Rosenstoch's health belief model addresses the relationship between a person's belief and behaviors. It predicts how clients will behave in relation to their health and how they will comply with their health regimen. The holistic health model creates conditions that promote optimal health.

During the day the nurse spends time instructing a client in how to self-administer insulin. After discussing the technique and demonstrating an injection, the nurse asks the client to try it. After the client makes two attempts it is clear that the client does not understand how to prepare the correct dose. The nurse discusses the situation with the charge nurse and asks for suggestions. This is an example of: A. Reflection B. Risk taking C. Problem solving D. Client assessment

C. Problem Solving This is an example of problem solving because the nurse is taking a problem to a supervisor for help in finding a different approach. Reflection is the process of purposefully thinking back and recalling a situation to discover its purpose or meaning. Risk taking involves trying a different approach. Client assessment is the first step in the process of instruction.

A client recently diagnosed with cervical cancer is going home after undergoing surgery. The client is avoiding discussion of her illness and postoperative orders. In going over discharge instructions with the client, the nurse: A) Teaches the client's spouse B) Focuses on knowledge the client will need in a few weeks C) Provides only the information the client needs to go home D) Convinces the client that learning about her health is necessary

C. Provides only the information teh client needs to go home Because this client does need to have some postoperative knowledge, the teaching should focus on the information the client will need until she has had a chance to move through the grief process. Teaching the spouse does not focus on caring for the client, although his knowledge can be helpful. Teaching ahead about information that the client will need in a few weeks is not appropriate. Until the client is able to process her grief, convincing her that learning about health is not productive.

The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall'." The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis

C. Reexamine the nursing orders The plan needs to be reassessed whenever the goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome.

The nurse is demonstrating the proper technique for using a glucometer to a group of clients newly diagnosed with diabetes. The nurse smiles and praises one of the clients when she correctly performs a finger stick. This teaching approach is referred to as: A) Timing B) Entrusting C) Reinforcing D) Group instruction

C. Reinforcing Social reinforcement includes smiles, compliments, or words of encouragement. Timing is not a teaching approach. It refers to the planning phase of the teaching process. Entrusting allows the client to manage his or her own care, with the nurse available for assistance if needed. A client newly diagnosed with diabetes would not be able to manage self-care. Group instruction is an instructional method, not a teaching approach.

Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means: A. Pulse rate greater than 100 beats per minute B. Blood pressure of 140/90 C. Respiratory rate greater than 20 breaths per minute D. Frequent bowel sounds

C. Respiratory rate greater than 20 breaths per minute A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds.

Which of the following terms is defined as a mental self-image of strengths and weaknesses in all aspects of one's personality? A) Body image B) Family roles C) Self-concept D) Emotional change

C. Self-concept Self-concept is a mental self-image of strengths and weaknesses in all aspects of one's personality. Self-concept is important in relationships with other family members. When a client is ill, his or her self-concept changes and this may lead to tension and conflict. Body image is defined as a subjective concept of physical appearance. Many illnesses can cause changes in physical appearance, and clients and families react differently to these changes. Clients react differently to illness or the threat of illness. Individual behavioral and emotional reactions depend on the nature of the illness. Illness impacts family roles. When an illness occurs, parents and children try to adapt to major changes resulting from a family member's illness.

All of the following are considered internal variables that influence a client's health beliefs and practices except: A) Emotional factors B) Developmental stage C) Socioeconomic factors D) Perception of functioning

C. Socioeconomic factors Socioeconomic factors are considered external variables. A person seeks approval and support from neighbors, peers, and co-workers; this affects health beliefs and practices. Economic variables may affect a client's level of health. For example, a client with a fixed income who needs long-term medications may determine that food and shelter are more important than the medication; therefore, the client's health suffers. Perception of functioning is an internal variable. It is defined as the way an individual perceives his or her physical functioning and how it affects health beliefs and practices. Emotional factors are internal variables. These include a client's degree of stress, depression, or fear, which can influence health beliefs and practices. An individual's developmental stage is considered an internal variable. A client's thinking about health is dependent on his or her level of development.

The clinical instructor is discussing about the Nursing Process. She mentioned that when a cluster of actual or high-risk diagnosis are present because of a certain situation it is called: A. Wellness nursing diagnosis B. Actual nursing diagnosis C. Syndrome nursing diagnosis D. Risk nursing diagnosis

C. Syndrome nursing diagnosis Presence of both actual and high-risk diagnosis is called a syndrome nursing diagnosis. Wellness nursing diagnosis focuses on the clinical judgment on an individual from a specific to higher level of wellness. Actual diagnoses are clinical judgment of the nurse that is validated. A risk diagnosis is based on the clinical are based on clinical judgment that the client may develop vulnerability to the problem.

A client comes into the clinic for a complete physical examination. The nurse obtains a health history and determines that the client is at risk for heart disease. Which of the following would lead the nurse to conclude this? A) The client is 25 years old. B) The client lives near a chemical plant. C) The client's father died of a heart attack at age 40. D) The client works as a carpet salesman.

C. The client's father died of a heart attack at age 40 Genetic predisposition to specific illnesses is considered a major physical risk factor. The client's father died of a heart attack at the age of 40, which increases the client's risk of heart disease and heart attack. Age may increase or decrease a client's susceptibility to certain illnesses. Age risk factors are often closely associated with other risk factors, such as family history and personal habits. The client is 25 years old; therefore, based on age alone, risk is low for heart disease at this time. The client lives near a chemical plant; this constant exposure to chemicals may lead to health problems. The physical environment in which a person works and lives can increase the likelihood that certain illnesses will occur, but without further information the nurse cannot assess the heart disease risk related to the client's possible chemical exposure.

A nurse is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment, the nurse anticipates the need to monitor the client's abdominal dressing, intravenous infusion, and drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. The nurse will have to establish priorities of care in which of the following situations? A) The family comes to visit the client. B) The client expresses concern about pain control. C) The client's vital signs change showing a drop in blood pressure. D) The charge nurse approaches the assigned nurse and requests a report at the end of the shift.

C. The client's vital signs change showing a drop in blood pressure A drop in blood pressure indicates a possible emergency situation, including bleeding at the surgical site. Concern about pain control, including a thorough assessment focusing the client's pain, would be the second priority. The end-of-shift report and the family's visit are lesser priorities.

In the examples given below, which nurse is acting to avoid a data collection error? A) The nurse asks her colleague to chart her assessment data. B) The nurse considers conflicting cues in deciding on the correct nursing diagnosis. C) The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her. D) After performing an assessment the nurse critically reviews his level of comfort and competence with interviewing and physical assessment skills.

C. The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her. A nurse who is uncertain and asks a colleague to consult is avoiding a data collection error. The nurse reviewing his level of comfort and competence is being complete but can miss his own errors. Considering conflicting clues does not help avoid data collection errors. Asking a colleague to chart data is incorrect.

4. There is a contemporary move toward addressing nursing as a science or as evidenced-based practice. This suggests that: A) One theory will guide nursing practice. B) Scientists will make nursing decisions. C) Theories will be tested to describe or predict client outcomes. D) Nursing will base client care on the practice of other sciences.

C. Theories will be testing to describe or predict client outcomes Theories will be tested to describe or predict client outcomes as nursing is addressed as a science and an art. Scientists will not make nursing decisions, and nursing will base client care on the practice of nursing science, which will be guided by multiple theories.

Which of the following statements about prescriptive theories is accurate? A) They describe phenomena. B) They have the ability to explain nursing phenomena. C) They reflect practice and address specific phenomena. D) They provide a structural framework for broad abstract ideas.

C. They reflect paractice and address specific phenomena Prescriptive theories address nursing interventions for a phenomenon and predict the consequence of a specific nursing intervention. Descriptive theories describe the phenomena, speculate on the reason the phenomena occur, and predict nursing phenomena. Grand theories are broad and complex and provide a structural framework for broad, abstract ideas about nursing.

12. The client who is most ready to begin a client teaching session is the client who has: A) Experienced nausea and vomiting for the past 24 hours B) Just been told that he needs to have major surgery C) Voiced a concern about how insulin injections will affect her lifestyle D) Complained bitterly about the low-fat, low-cholesterol diet he must follow after his heart attack

C. Voiced a concern about how insulin injections will affect her lifestyle

A client says to the nurse, "It was a stupid thing that I did. If I had just stayed home, this car accident wouldn't have happened." The nurse's best response is: A) "So, why did you go out?" B) "Why would you say that?" C) "If I were you, I'd quit worrying about it. You can't change the past." D) "You feel responsible for the accident, as though it could've been prevented."

D) "You feel responsible for the accident, as though it could've been prevented." Option 4 demonstrates the therapeutic communication technique of paraphrasing. Paraphrasing is restating another's message more briefly using one's own words. Through paraphrasing, the nurse sends feedback that lets the client know that the nurse is actively involved in the search for understanding. Asking for explanations is a nontherapeutic communication technique. Giving one's personal opinion is also nontherapeutic. Asking personal questions that are not relevant to the situation to satisfy the nurse's curiosity is both nontherapeutic and nonprofessional.

A client with known chronic obstructive pulmonary disease (COPD) is admitted to the emergency department with multiple minor injuries following an automobile accident. To ensure adequate ventilation the nurse applies a nasal cannula providing oxygen at what rate and for what reason? A) 6 L/min to provide sufficient oxygen to the myocardium following trauma B) 3 L/min to stimulate the respiratory chemoreceptors, which will result in increased respiratory rate C) 10 L/min to suppress the respiratory drive, which is necessary for adequate artificial ventilation D) 2 L/min to prevent elevating the arterial oxygen tension (PaO2), which would suppress the hypoxic drive

D) 2 L/min to prevent elevating the arterial oxygen tension (PaO2), which would suppress the hypoxic drive Clients without COPD rely on low PaO2 as a stimulus to breathe. Thus, increasing the PaO2 would stop the client from breathing. Low oxygen therapy is recommended for clients with COPD who are severely hypoxic. Options 1 and 2 give the client too much oxygen and might suppress the client's breathing. Because the client experienced only minor injuries, the client presumably is still breathing on his or her own; therefore, option 3 is incorrect because artificial ventilation is not necessary.

A cleansing enema is ordered for a 55-year-old client before intestinal surgery. The maximum amount of fluid used is: A) 150 to 200 ml B) 200 to 400 ml C) 400 to 750 ml D) 750 to 1000 ml

D) 750 to 1000 ml

7. A nurse trained to care for ostomy clients is: A) A gastrointestinal therapist B) A nurse practitioner. C) An ostomy practitioner D) A wound-ostomy-continence nurse

D) A wound-ostomy-continence nurse

After returning from vacation, the nurse notices that the client has been receiving Percocet, 2 tablets by mouth every 3 hours for the past 3 days. The nurse is most concerned about which of the following? A) Risk for gastrointestinal bleeding B) Client's level of pain C) Potential for addiction D) Amount of acetaminophen received daily

D) Amount of acetaminophen received daily The maximum dosage of acetaminophen is 4 g every 24 hours. This client is receiving 5.6 g, which could cause liver damage. A check of the client's level of pain to assess the need for the high dose of acetaminophen could indicate that the client requires a different medication. The potential for addiction if the client is taking the medication as prescribed is minimal. Gastrointestinal bleeding is usually associated with the use of nonsteroidal antiinflammatory drugs.

After a client receives 0.2 mg of naloxone via intravenous push, the client's respiratory rate and depth are within normal limits. The nurse now plans to implement which of the following actions? A) Discontinue all ordered opioids. B) Close the room door to allow the client to recover. C) Administer the remaining naloxone over 4 minutes. D) Assess the client's vital signs every 15 minutes for 2 hours.

D) Assess the client's vital signs every 15 minutes for 2 hours. Clients who receive naloxone should be reassessed every 15 minutes for 2 hours after drug administration because of the risk of renarcotization and the return of respiratory depression. The nurse should not close the door to the room or leave the client where the client cannot be observed quickly. If the dose was effective, there is no need to give a further dose unless the client shows signs of renarcotization. The type and dosages of opioids should be reevaluated

A couple has brought in their adolescent daughter for a school physical. The parents tell the nurse that they are worried about all the safety risks for this age group. As the nurse plans to teach the parents about these risks, the nurse remembers that adolescents are at a greater risk for injury from: A) Home accidents B) Poisoning and child abduction C) Physiological changes of aging D) Automobile accidents, suicide, and substance abuse

D) Automobile accidents, suicide, and substance abuse Adolescents are more likely to be involved in automobile accidents, commit suicide, and engage in substance abuse than are those in other age groups. Children are more susceptible to poisoning and child abduction, and older adults are more susceptible to home accidents and the physiological changes of aging.

6. A gown should be worn when: A) The client's hygiene is poor. B) The client has acquired immunodeficiency syndrome (AIDS) or hepatitis. C) The nurse is assisting with medication administration. D) Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.

D) Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform. Gowns should be worn when there is a possibility that blood or body fluids could get on the nurse's clothes or when the client is on contact isolation status. The other options are not appropriate uses of gowns.

Some medications change the color of the urine. Pyridium colors the urine: A) Blue B) Brown C) Yellow D) Bright orange to rust

D) Bright orange to rust

A nurse working in a nursing home decides to implement a stringent mouth care protocol. The most important reason to establish this protocol is that proper oral care: A) Prevents the formation of caries B) Improves the client's self-image C) Minimizes the occurrence of halitosis D) Can reduce the incidence of pneumonia in the elderly

D) Can reduce the incidence of pneumonia in the elderly Proper oral care reduces the bacterial count in oral secretions, which decreases the risk of bacterial pneumonia if oral secretions are aspirated. The other options are all true; however, they are not the most important reason for adequate mouth care, although they are additional positive outcomes

A child for which the nurse is caring in the hospital starts to have a grand mal seizure while playing in the playroom. What is the most important intervention the nurse can do during this situation? A) Begin cardiopulmonary resuscitation. B) Restrain the child to prevent injury. C) Place a tongue blade over the tongue to prevent aspiration. D) Clear the area around the child to protect the child from injury.

D) Clear the area around the child to protect the child from injury. An area around the child should be cleared to prevent injury. Restraining the child or placing a tongue blade in the child's mouth may actually be a cause of injury. Cardiopulmonary resuscitation is required only if heart function stops after the seizure.

In a nurse-client helping relationship, the nurse should: A) Problem solve for the client. B) Distort the truth when the client is to receive bad news to protect the client. C) Convey acceptance by always agreeing with the client or approving of the client's decisions or actions. D) Convey nonjudgmental acceptance with a willingness to hear a message or to acknowledge feelings.

D) Convey nonjudgmental acceptance with a willingness to hear a message or to acknowledge feelings. The nurse-client helping relationship is characterized by the nurse's nonjudgmental acceptance of the client. Acceptance conveys a willingness to hear a message or to acknowledge feelings even if the nurse does not agree with the client. Acceptance does not mean the nurse must always agree with the client. The nurse should allow others the opportunity to make choices and help them problem solve, but not make decisions for them. The nurse acts as an advocate, keeping the client informed and providing support in decision making. Lying or distorting the truth violates both legal and ethical standards of practice.

5. Left-sided heart failure is characterized by: A) Increased cardiac output B) Lowered cardiac pressures C) Decreased functioning of the left atrium D) Decreased functioning of the left ventricle

D) Decreased functioning of the left ventricle Left-sided heart failure is an abnormal condition characterized by decreased functioning of the left ventricle. If left ventricular failure is significant, the amount of blood ejected from the left ventricle drops greatly, which results in decreased cardiac output.

Which of the following signs or symptoms in an opioid-naïve client is of greatest concern to the nurse when assessing the client 1 hour after administering an opioid? A) Respiratory rate of 10 breaths per minute B) Oxygen saturation of 95% C) Pain intensity rating of 5 on a scale of 10 D) Difficulty arousing the client

D) Difficulty arousing the client Sedation always occurs before respiratory depression, so the nurse should monitor for sedation or difficulty arousing the client. A pain intensity rating of 5 on a scale of 10 means that the client probably needs a higher dose of medication. The oxygen saturation and respiratory rate are probably acceptable but should be compared with the client's baseline values for vital signs.

8. The nurse is developing a plan of care for a client experiencing narcolepsy. Which intervention is appropriate to include on the plan? A) Instruct the client to increase carbohydrates in the diet. B) Preserve energy by limiting exercise to morning hours. C) Have client limit fluid intake two hours before bedtime. D) Encourage client to take one or two 20-minute naps during the day.

D) Encourage client to take one or two 20-minute naps during the day. Brief daytime naps of no longer than 20 minutes help reduce subjective feelings of sleepiness. Carbohydrates can increase sleepiness. Limiting fluids will not help the client with narcolepsy, nor will energy preservation.

What nursing measure promotes sleep in school-aged children? A) Encourage evening exercise. B) Encourage television viewing. C) Make sure the room is dark and quiet. D) Encourage quiet activities prior to bedtime.

D) Encourage quiet activities prior to bedtime. Encouraging quiet activities before bedtime helps prepare children for sleep. Evening exercise and watching television can make falling asleep more difficult. Children may sleep better with a night light in the room.

A simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion is: A) Administration of antiinfectives B) Chest physiotherapy C) Oxygen humidification D) Frequent change of position

D) Frequent change of position Changing the client's position frequently is a simple and cost-effective method for reducing the risk of pneumonia associated with stasis of pulmonary secretions and decreased chest wall expansion. Oxygen humidification, chest physiotherapy, and use of antiinfectives are all helpful, but are not cost effective.

A client receiving an anticoagulant questions the nurse about mouth care. Which of the following mouth care practices would the nurse recommend? A) Obtaining an electric toothbrush to use for teeth cleaning B) Gargling with an alcohol-based mouthwash after each meal C) Brushing the teeth 2 or 3 times a day using a hard-bristle brush D) Gently flossing between the teeth once a day or more using unwaxed floss

D) Gently flossing between the teeth once a day or more using unwaxed floss Vigorous flossing is to be avoided because it may cause the gums to bleed. Use of unwaxed floss encourages gentle flossing. Toothbrushes should be soft, not hard. Hard bristles may cause bleeding at the gums. Although an electric toothbrush is nice to have, it is not required. Many clients may not be able to afford an electric toothbrush. Alcohol is drying to the mucous membranes of the mouth. This could lead to cracking and bleeding. It is best to avoid these harsh products.

A person who starts smoking in adolescence and continues to smoke into middle age: A) Has an increased risk for alcoholism B) Has an increased risk for obesity and diabetes C) Has an increased risk for stress-related illnesses D) Has an increased risk for cardiopulmonary disease and lung cancer

D) Has an increased risk for cardiopulmonary disease and lung cancer The risk of lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Cigarette smoking worsens peripheral vascular and coronary artery disease. Inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood pressure and decreasing blood flow to peripheral vessels.

Hospital-acquired urinary tract infections (UTIs) are often related to poor hand washing and: A) Poor urinary output B) Poor perineal hygiene C) Use of urinary drainage bags D) Improper catheter care

D) Improper catheter care Although all the answers may be causes of UTIs, in the hospital, urinary catheterization has the highest potential for causing UTIs, and improper catheter care can increase the chance of these infections. Poor perineal hygiene can also increase the risk of UTIs, both in and out of the hospital. Poor urinary output does increase the chance of UTIs, in and out of the hospital.

Which of the following statements reflects the current trend in the directives from the Centers for Disease Control and Prevention (CDC) for minimizing risks of infection? A) Discard all dressings into red bags. B) Do not recap bottles of solutions to minimize risk of contamination. C) Recap syringes or break needles off before discarding into sharps containers. D) Keep all drainage tubing below the level of the waist and/or site of insertion.

D) Keep all drainage tubing below the level of the waist and/or site of insertion. Keeping the solution in drainage tubes draining away from the drainage site on the body reduces the risk for bacteria growth. Running any solution backward in the tubing puts the client at risk by bringing any bacteria that may be present lower in the system back to the body, and cross contamination will occur. As in surgical areas, anything below the waist should be considered at potential risk for infection. Needles are not to be recapped or cut because of the increased risk of experiencing puncture wounds while doing so. Not all dressings need to be placed in red bags; only dressings with moisture require placement in a red bag. Bottles of solution that are sitting in the client's room should be closed to prevent airborne contaminants from entering and creating an unsterile situation.

A nurse is meeting a 3 year old for the first time. Communication with the child will be facilitated if the nurse: A) Ignores the child B) Lifts the child onto the nurse's lap C) Distracts the child by clapping the hands D) Kneels down while holding and talking to a teddy bear

D) Kneels down while holding and talking to a teddy bear Kneeling down puts the nurse at the child's eye level. Holding and talking to a teddy bear is nonthreatening and allows the child to make the first move in interpersonal contacts. Children are especially responsive to nonverbal messages, and sudden movements, loud noises, or threatening gestures can be frightening. Lifting a child onto the nurse's lap may be very threatening to the child because the nurse is invading the child's personal space. Ignoring the child will not facilitate communication.

Older adults are cautioned about the use of nonprescription sleeping medications because these medications can: A) Cause headaches and nausea. B) Be expensive and difficult to obtain. C) Cause severe depression and anxiety. D) Lead to further sleep disruption even when they initially seemed to be effective.

D) Lead to further sleep disruption even when they initially seemed to be effective. Over-the-counter medications for sleep often cause more problems than benefits. The other answers are incorrect.

The nurse finds a client sleepwalking down the unit hallway. An appropriate intervention the nurse implements is: A) Blocking the hallway with chairs and seating the client. B) Asking the client what he or she is doing and calling for help. C) Quietly approaching the client and then loudly calling his or her name. D) Lightly tapping the client on the shoulder and leading him or her back to bed.

D) Lightly tapping the client on the shoulder and leading him or her back to bed. The nurse should not startle the client but should gently awaken the client and lead him or her back to bed. Sleepwalkers are unaware of their surroundings. Asking them what they are doing is not helpful. The nurse may or may not need assistance. Startling the client may result in injury. Blocking the walkway with chairs may result in injury.

Clients will experience conditions that threaten the integrity of the oral mucosa; therefore: A) No mouth care is needed. B) Less oral hygiene is needed. C) No antiinfective agents are needed. D) More frequent mouth care is needed

D) More frequent mouth care is needed Clients with conditions that pose greater risk to the integrity of the oral mucosa need more frequent mouth care to ensure that the mouth is clean and free of infection.

13. A client describes the pain radiating down the leg as sharp, shooting, and electric-like. The nurse recognizes this as indicative of: A) Somatic pain B) Visceral pain C) Idiopathic pain D) Neuropathic pain

D) Neuropathic pain Neuropathic pain is usually described as burning, shooting, or electric-like. It is important to report these characteristics to the physician, because neuropathic pain may not respond as well to opioids. Visceral and somatic pain are often described as "aching," "throbbing," and "pounding." Idiopathic pain does not have specific descriptive terms.

A client's personal preferences for hygiene are influenced by a number of factors. The nurse must recognize that: A) The nurse is in charge of the care. B) Hygiene care is a routine procedure. C) Hygiene has no influence on client outcomes. D) No two individuals perform hygiene in the same manner.

D) No two individuals perform hygiene in the same manner. Each individual performs personal hygiene in his or her own manner, and the nurse should respect the client's wishes. Hygiene can be a routine procedure, but the routine changes with client preferences. Hygiene can influence client outcomes.

When transferring a sterile item to a sterile field, the nurse should: A) Open the outer package and let the sterile assistant take the item from the nurse to put on the edge of the drape. B) Use a sterile lifting tool (forceps) to pick up the inner package and transfer it to the middle of the field. C) Open the outer package and use a sterile glove to pick up the item and drop it on the sterile field in the middle of the drape. D) Open the package by peeling back the cover without touching the inner package and drop the item within the sterile field without touching the 1-inch border.

D) Open the package by peeling back the cover without touching the inner package and drop the item within the sterile field without touching the 1-inch border. The rule is "sterile to sterile" to prevent contamination. The outer cover is considered unsterile. As long as the inner packet is not touched, the packet is considered sterile. The 1-inch border or barrier between the edge of the drape and the field is the dividing line for sterile versus nonsterile. Using a sterile glove to remove the inner packet is all right, but dropping it into the middle of the field will contaminate other items. A sterile assistant can take the item from the nurse, but placing it on the edge of the drape will contaminate the item because it is not inside the 1-inch border/barrier. Using sterile forceps to remove the inner packet is acceptable, but putting the item into the middle of the field will again risk potential contamination from reaching over the sterile field.

A client with chronic low back pain who has been receiving an opioid around the clock for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this client is experiencing symptoms of: A) Addiction B) Tolerance C) Pseudoaddiction D) Physical dependence

D) Physical dependence Physical dependence results after a client has been taking a medication for a period of time. This is not addiction, which occurs when an individual takes medication for reasons other than its intended use. This also is not pseudoaddiction or tolerance.

During the night shift a client is found wandering the hospital halls looking for a bathroom. The nurse's initial intervention would be to: A) Insert a urinary catheter. B) Ask the physician to order a restraint. C) Assign a staff member to stay with the client. D) Provide scheduled toileting during the night shift.

D) Provide scheduled toileting during the night shift. Providing scheduled toileting during the night makes it less likely that a client will wander while being confused and ensures staff presence to decrease confusion at the times when the client is away from bed. Inserting a urinary catheter is not necessary. Assigning a staff member to stay with the client might not be necessary if the scheduled toileting is successful. Restraints are unnecessary in this case.

5. Lisa, a nurse assistant, is working with the nurse during the nurse's shift. One of the nurse's clients has upper limb restraints. In delegating care of this client to Lisa, the nurse would tell her to: A) Secure the restraints to the side rails. B) Check to see if the client can have a medication for sleep. C) Call the physician if the client becomes more agitated with the restraint. D) Report any signs of redness, excoriation, or constriction of circulation under the restraint.

D) Report any signs of redness, excoriation, or constriction of circulation under the restraint. The restraint sites much be checked regularly for signs of redness, excoriation, or constriction, and this task may be delegated. Calling the physician and performing medication assessments are nursing responsibilities. Restraints should never be secured to the side rails.

A client who recently experienced a bout of diarrhea is requesting something to drink. There is an order to force clear liquids to prevent fluid and electrolyte imbalance. The nurse decides to give the client: A) Ice cream B) A cold fruit pop C) A cup of hot coffee D) Room-temperature bouillon

D) Room-temperature bouillon Hot and cold foods (options 1, 2, and 3) stimulate peristalsis, which can cause abdominal cramping and further diarrhea. Thus room-temperature liquids are better tolerated. Bouillon also contains some electrolytes that may prevent electrolyte imbalance. Ice cream is not a clear liquid.

Diarrhea that occurs with a fecal impaction is the result of: A) A clear liquid diet B) Irritation of the intestinal mucosa C) Inability of the client to form a stool D) Seepage of stool around the impaction

D) Seepage of stool around the impaction Although a mass of solid matter may obstruct the large intestine, liquid stool may leak around the obstruction (impaction). A clear liquid diet is not the cause of the diarrhea, nor is irritation of the intestinal mucosa. This type of diarrhea is not caused by the inability of the client to form stool.

After the nurse assists a client with a history of seizures to a recliner chair, the client begins to have a seizure. The nurse should immediately: A) Turn the client onto his or her stomach. B) Recline the client's chair all the way back. C) Return the client to the bed and place the client on his or her side. D) Slide the client to the floor and cradle the client's head in the nurse's lap.

D) Slide the client to the floor and cradle the client's head in the nurse's lap. The nurse's lap is the safest position for the client's head, and the client is less likely to sustain an injury if the client is already on the floor. Attempting to move the client laterally by oneself could result in injury to the client and/or nurse. Placement in a reclining position could cause excess secretions to accumulate in the oral pharynx and obstruct the airway. Turning the client onto his or her stomach would decrease access to the airway.

When a condom catheter is applied, the catheter should be secured on the penile shaft in such a manner that the catheter is: A) Tight and draining well B) Dependent and draining well C) Secured with adhesive tape applied in a circular pattern D) Snug and secure but without causing constriction that impedes blood flow

D) Snug and secure but without causing constriction that impedes blood flow A condom catheter should fit snugly and securely but should not cause constriction that impedes blood flow. It should not be tight or placed in a dependent position, and should never be secured with tape in a circular pattern, which could impede blood flow.

4. A nurse is assigned to care for a client with a deep wound infection. Which of the following actions would result in the contamination of sterile gloves? A) The nurse grasps a sterile cotton-tipped swab to clean wound edges. B) The nurse takes a gauze pad in hand and places it in the wound. C) The nurse picks up a gauze pad soaked in sterile saline to cleanse the wound. D) The nurse pulls up the sheet over the client's perineum for better draping.

D) The nurse pulls up the sheet over the client's perineum for better draping. If the nurse touches a sheet (nonsterile) with sterile gloves, the gloves are contaminated. The other actions do not contaminate sterile gloves.

Which of the following is an example of a positive outcome of a nurse?health team relationship? A) The nurse becomes an effective change agent in the community. B) The nurse better understands the family dynamics that affect the client. C) The nurse better appreciates what the client perceives as meaningful from the client's perspective. D) The nurse receives encouragement and support from co-workers to cope with the many stresses associated with the nursing role.

D) The nurse receives encouragement and support from co-workers to cope with the many stresses associated with the nursing role. Benefits of positive nurse/health team relationships include building morale and strengthening bonds so that team members can help one another cope with the stresses of working in the health care field. Option 1 is a positive outcome of an effective nurse/community relationship, whereas option 2 describes an outcome of a nurse?family relationship. A benefit of narrative interactions in a nurse-client helping relationship is increased understanding, as in option 3.

Most nutrients and electrolytes are absorbed in: A) The colon B) The stomach C) The esophagus D) The small intestine

D) The small intestine The small intestine (specifically the duodenum and jejunum) absorb most of the nutrients and electrolytes. The ileum absorbs certain vitamins, iron, and bile salts. The colon absorbs water, sodium, and chloride from the digested food that has passed from the small intestine. The esophagus moves food from the mouth to the stomach.

A nurse feels frustrated because she is behind in administering her clients' medications. She comes to the client's bedside hurriedly with a frown on her face and sighs while she is waiting for the client to swallow the medication. The nurse then says brightly, "Isn't it a relaxing day?" The nurse should remember that: A) The client may respond defensively if his or her personal space is threatened. B) Maintaining eye contact during conversation shows respect and willingness to listen. C) Most meaning in conversation is transmitted by spoken words rather than by nonverbal communication. D) When there is incongruity between verbal and nonverbal communication, the receiver usually "hears" the nonverbal message as the true message.

D) When there is incongruity between verbal and nonverbal communication, the receiver usually "hears" the nonverbal message as the true message. It has been estimated that approximately 7% of meaning is transmitted by words, 38% is transmitted by vocal cues, and 55% is transmitted by body cues. Nonverbal communication is unconsciously motivated and may more accurately indicate a person's intended meaning than the spoken words. This is what the receiver "hears." Although options 1 and 2 are true, they are not the best statements for explaining incongruity between verbal and nonverbal communication as depicted in the question.

The professional nurse can best be said to be engaging in collaboration with others to develop the client's plan of care when the nurse: A) Consults the physician for direction in establishing goals for clients B) Depends on the latest literature to complete an excellent plan of care for clients C) Works independently to plan and deliver care and does not depend on other staff for assistance D) Works with colleagues and clients' families to take advantage of combined expertise in planning care

D) Works with colleagues and clients' families to take advantage of combined expertise in planning care Collaboration is teamwork in which individuals in multiple disciplines work together, each contributing his or her expertise to the client's care. The physician will provide medical direction, but teamwork and collaboration require more than just medical direction. Consulting the latest literature can help in planning care, but this is not collaboration. The collaborative team works together to provide care for the client.

When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position? A. 30 degrees B. 90 degrees C. 45 degrees D. 0 degree

D. 0 degree The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings.

The average daily amount of urine excreted by an adult is: A. 500 to 600 ml B. 800 to 1,400 ml C. 1,000 to 1,200 ml D. 1,500 to 2,000 ml

D. 1,500-2,000 ml An adult's average urine output ranges between 1,500 and 2,000 ml/day.

The nurse is aware that Bell's palsy affects which cranial nerve? A. 2nd CN (Optic) B. 3rd CN (Occulomotor) C. 4th CN (Trochlear) D. 7th CN (Facial)

D. 7th CN (Facial) Bells' palsy is the paralysis of the motor component of the 7th cranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat naso-labial fold and loss of taste on the affected side of the face.

Mishel's theory of uncertainty in illness focuses on the experience of clients with cancer who live with continual uncertainty. The theory provides a basis for nurses to assist clients in appraising and adapting to the uncertainty and illness response and can be described as: A) A grand theory B) A descriptive theory C) A prescriptive theory D) A middle-range theory

D. A middle-range theory Middle-range theories are limited in scope, less abstract than grand theories, address specific phenomena or concepts, and reflect practice. Grand theories are described as broad and complex. Prescriptive theories address nursing interventions and predict the consequence of a specific nursing intervention. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena

One of Nurse Cathy's co-workers is Annie who is flexible in any given situation. Annie is performing her duties well without supervision but still needs more experience and practice to develop a consciously planned nursing care. According to Patricia Benner's category in specialization in nursing, Annie is a/an: A. Novice B. Expert C. Competent D. Advanced beginner

D. Advanced beginner A- Novice is governed by rules and usually inflexible. B- Expert nurses have intuitive grasp on the situation dealt. C- Competent nurses are planning nursing care consciously. D- Advanced beginners demonstrate acceptable performance.

An older man is being given a new antihypertensive medication. In teaching the client about the medication, the nurse should: A) Speak loudly. B) Present the information once. C) Expect the client to understand the information quickly. D) Allow the client time to express himself and ask questions.

D. Allow the client time to express himself and ask questions The nurse should allow the client time to express himself and ask questions. Speaking loudly is typically not effective, and information may have to be presented several times. The client will learn the information at his own speed.

On entering a client's room during change-of-shift rounds, the nurse notices that the client and spouse have their backs turned to each other, and both have their arms folded across their chests. The best action for the nurse to take at this time is to: A) Introduce himself or herself and begin discharge teaching. B) Proceed with the tasks the nurse was intending to perform. C) Say nothing and leave quickly, closing the door behind. D) Ask the client and spouse if they need some time alone right now.

D. Ask the client and spouse if they need smoe time alone right now. The situation suggests that the nurse entered during a stressful time. Offering privacy would be appropriate. Because the situation indicates tension between the couple, this is not the time to initiate teaching.

What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection? A. Use sterile gloves when obtaining urine B. Open the drainage bag and pour out the urine C. Disconnect the catheter from the tubing and get urine D. Aspirate urine from the tubing port using a sterile syringe

D. Aspirate urine from the tubing port using a sterile syringe The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection.

During a physical assessment, the nurse closes and door and provides drape to promote privacy. The nurse is performing her role as a/an: A. Advocate B. Communicator C. Change agent D. Caregiver

D. Caregiver The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness by viewing a person holistically. As an advocate the nurse intercedes or works on behalf of the client. Identifying the need and problems of the client and communicating it to other members of the health team is doing the role of a communicator. As a change agent, the nurse assists the client to MODIFY their BEHAVIOR.

Which of the following is an example of an expected outcome statement in measurable terms? A) Client will be pain free. B) Client will have less pain. C) Client will take pain medication every 4 hours. D) Client will report pain intensity of less than 4 on a scale of 0 to 10.

D. Client will report pain intensity of less than 4 on a scale of 0 to 10 Reporting the level of pain on a numbered scale is a measurable, objective goal. The other options do not specify measurable outcomes.

The surgical unit has initiated the use of a pain rating scale to assess the severity of clients' pain during their postoperative recovery. The nurse assigned to a client can look at the pain flow sheet to see the client's pain scores over the last 24 hours. Use of the pain scale is an example of adherence to which intellectual standard?

D. Consistency Using the same pain scale for all clients and ratings promotes consistency—each nurse has the same measurement scale to compare assessments. Relevance refers to how applicable the assessment is. An assessment has depth when it deals with less obvious issues. Specificity refers to the ability of the assessment to provide information about the particular problem of interest.

The nurse requests a stimulant laxative for a client who is receiving an opioid around the clock. What is the nurse demonstrating? A) Concern for safety B) Promotion of client health C) Colleague health education D) Control of adverse reactions

D. Control of adverse reactions The nurse is demonstrating knowledge of opioid side effects and being proactive by asking for an intervention that will most likely prevent the side effect of constipation associated with opioids. The intervention does not promote health; it is aimed at preventing a side effect of an opioid. Safety is not an issue. Requesting a laxative does not provide education.

Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response? A. Low blood pressure B. Warm, dry skin C. Decreased serum sodium levels D. Decreased urine output

D. Decreased urine output Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.

A theory is a set of concepts, definitions, relationships, and assumptions or propositions to explain a phenomenon. The purposes of the components of a theory are to: A) Describe concepts or connect two concepts that are factual B) Formulate a perceptual experience to describe or label a phenomenon C) Express the global view about the individual, situations, or factors of interest to a specific discipline D) Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the phenomenon

D. Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the phenomenon Describing, explaining, predicting, and/or prescribing interrelationships among concepts are stated purposes of research.

During the change-of-shift report the night nurse states that a client mentioned having a bad experience with surgery in the past. The nurse was called away and was unable to continue the conversation with the client. The nurse tells the day shift nurse about the comment and notes that the client appears anxious. When the day shift nurse visits the client to clarify the client's bad experience with surgery, the nurse is exhibiting which aspect of critical thinking? A. Integrity B. Discipline C. Confidence D. Perseverance

D. Discipline Discipline includes completing the task at hand, including assessments (which were not completed on the previous shift). Integrity includes recognizing when one's opinions conflict with those of others and finding a mutually satisfying solution. Confidence is demonstrated in one's presentation and belief in one's knowledge and abilities. Perseverance helps the critical thinker to find effective solutions to client care problems, especially when they have been previously unresolved.

The nurse reviews data regarding a client's pain symptoms, comparing the defining characteristics for Acute pain with those for Chronic pain. In the end the nurse selects Acute pain as the correct diagnosis. This is an example of avoiding which type of error? A) Error in data clustering B) Error in data collection C) Error in data interpretation D) Error in making a diagnostic statement

D. Error in making a diagnostic statement When a nurse compares collected assessment data with defining characteristics for two diagnoses, the selection of the correct diagnosis is an example of avoiding an error in making a diagnostic statement. There is no indication the data clustering or interpretation were incorrect.

The purpose of assessment is to: A) Make a diagnostic conclusion. B) Delegate nursing responsibility. C) Teach the client about his or her health. D) Establish a database concerning the client.

D. Establish a database concerning the client The purpose of assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. The data also reveal related experiences, health practices, goals, values, and expectations. The other options are not purposes of assessment.

Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation

D. Evaluation Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating the nursing interventions.

Which of the following is objective information to be recorded in the client's medical record? A) Anxious over upcoming test. B) Increasing stress over past 2 months. C) Performs breast self-examination monthly. D) Expelled 1 tablespoon of yellow sputum.

D. Expelled 1 tablespoon of yellow sputum Objective data are measurable data. Options 1, 2, and 3 describe data that cannot be measured by the nurse but depend on the client's reports; thus they are subjective data.

One of the purposes of the use of standard formal nursing diagnostic statements is to: A) Evaluate nursing care. B) Gather information on client data. C) Help nurses to focus on the role of nursing in client care. D) Facilitate understanding of client problems by different health care providers.

D. Facilitate understanding of client problems by different health care providers. The use of standard formal nursing diagnostic statements provides a precise definition that gives all members of the health care team a common language for understanding the client's needs. The other options are not part of the reason for the development of nursing diagnostic statements.

All of the following are examples of active strategies of health promotion except: A) Exercise training B) Weight reduction C) Smoking cessation D) Fluoridation of drinking water

D. Fluoridation of drinking water Passive strategies of health promotion benefit individuals without any action by the individuals themselves. The fluoridation of municipal drinking water and the fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. Weight reduction is considered an active strategy of health promotion. With active strategies of health promotion, individuals are motivated to adopt specific health programs. Smoking cessation requires clients to be actively involved in measures to improve their present and future levels of wellness while decreasing the risk of disease. Exercise training meets the criteria for active strategies of health promotion because it actively involves the client in his or her own health.

A nurse assessing a client who comes to the pulmonary clinic asks, "Tell me what medications you are taking for your breathing problem. I see from your last visit that Dr. Russell recommended routine exercise. Can you also tell me how successful you have been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? A) Value-belief pattern B) Cognitive-perceptual pattern C) Coping/stress tolerance pattern D) Health perception/health management pattern

D. Health perception/health management patern The health perception/health management pattern involves the client's self-report of health and well-being, how the client manages his or her health, and knowledge of preventative health practices. The cognitive-perceptual pattern involves sensory-perceptual patterns, language adequacy, memory, and decision-making abilities. The coping/stress tolerance pattern involves the client's ability to manage stress, sources of support, and the effectiveness of the patterns in terms of stress tolerance. The value-belief pattern involves the values, beliefs, and goals that guide the client's choices or decisions.

Assessment data must be descriptive, concise, and complete. In performing an assessment the nurse should not: A) Include subjective data from the client. B) Perform a thorough physical examination. C) Use interpersonal and cognitive skills. D) Include inferences or interpretative statements not supported with data.

D. Include inferences or interpretative statements not supported with data The nurse should not generalize or form judgments not supported by the collected data. Inferences and interpretive statements must be supported by data. Assessments do include conducting a thorough physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the client.

Kussmaul's breathing is: A. Shallow breaths interrupted by apnea B. Prolonged gasping inspiration followed by a very short, usually inefficient expiration C. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea D. Increased rate and depth of respiration

D. Increased rate and depth of respiration Kussmaul breathing is also called as hyperventilation. Seen in metabolic acidosis and renal failure. Option A refers to Biot's breathing. Option B is apneustic breathing and option C is the Cheyne-stokes breathing.

A nurse has set a time limit for expected outcomes. What is the purpose of establishing such a time frame? A) Indicate which outcome has priority. B) Indicate the time it takes to complete an intervention. C) Indicate how long the nurse is scheduled to care for the client. D) Indicate when the client is expected to respond in the desired manner.

D. Indicate when the client is expected to respond in the dsired manner The time limit sets measurable points to evaluate the client's response and movement toward meeting the outcome goals. The other options are incorrect.

The health belief model addresses the relationship between a person's belief and behaviors, therefore: A) A person who smokes does not follow the model. B) This model provides a basis for caring for clients of all ages. C) A person who does not take necessary medications does not follow the model. D) It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens.

D. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens. The health belief model provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens.

When performing an admission assessment on a newly admitted patient, the nurse percusses resonance. The nurse knows that resonance heard on percussion is most commonly heard over which organ? A. Thigh B. Liver C. Intestine D. Lung

D. Lung Resonance is loud, low-pitched and long duration that's heard most commonly over an air-filled tissue such as a normal lung.

A client who is alert and awake is being transferred to another hospital with a copy of his medical records. Before the transfer the nurse must: A) Ask the hospital lawyer if this requires approval from the risk management department. B) Discuss the need to copy the medical records with the client's family. C) Be certain that the physician writes an order for the record to be copied. D) Obtain written permission to copy the medical records for the receiving hospital.

D. Obtain written permissin to copy the medical records for the receiving hospital Obtaining permission to copy the records demonstrates the nurse's understanding of the provisions of the Health Insurance Portability and Accountability Act (HIPAA). Discussing medical records with the client's family is inappropriate because the client's family does not make the decision for a client who is capable of making his own decision. Policies and procedures would already be in place for the nurse with regard to copying medication records. It is not necessary to call the hospital lawyer. Copying a client's medical record does not require a physician's order.

During data clustering, a nurse: A) Provides documentation of nursing care B) Reviews data with other health care providers C) Makes inferences about patterns of information D) Organizes cues into patterns that lead to identification of nursing diagnoses

D. Organizes cues into paterns that lead to identification of nursing diagnoses During data clustering, the nurse organizes cues into patterns that indicate individualized nursing diagnoses and identify collaborative problems. The other options are incorrect.

Which of the following represents the most complex behavior in the psychomotor learning domain? A) Accepting the limitations imposed by a stroke B) Understanding the relationship of insulin, diet, and exercise in diabetes C) Performing self-catheterization without acquiring a urinary tract infection D) Performing activities of daily living after acquiring left-sided paralysis due to a brain injury

D. Performing activities of daily living after acquiring left-sided paralysis due to a brain injury Origination is the most complex behavior in the psychomotor learning domain. It is highly complex and involves developing new psychomotor skills and abilities from existing ones, as is seen in paralysis. Accepting limitations is a behavior in the affective learning domain. Understanding relationships is a behavior in the cognitive learning domain. Option 3 is a psychomotor learning behavior that is referred to as complex overt response, in which the client performs a motor skill using a complex movement pattern. It is not as complex as origination.

A client needs to learn to use a walker. Acquisition of this skill will require learning in which domain? A) Affective domain B) Cognitive domain C) Attentional domain D) Psychomotor domain

D. Psychomotor domain The psychomotor domain concerns motor skills. The cognitive domain involves understanding, and the affective domain involves attitudes. The attentional domain is not a recognized domain. Attentional set is the mental state that allows the learner to focus on and comprehend a learning activity.

Pia's serum sodium level is 150 mEq/L. Which of the following food items does the nurse instruct Pia to avoid? A. Broccoli B. Sardines C. Cabbage D. Tomatoes

D. Sardines The normal serum sodium level is 135 to 145 mEq/L, the client is having hypernatremia. Pia should avoid food high in sodium like processed food. Broccoli, cabbage and tomatoes are good source of Vitamin C.

A client with diabetes mellitus who takes daily insulin injections is scheduled for surgery the next day. The client is to take nothing by mouth (NPO status) after midnight. The nurse questions whether insulin should be given the morning of surgery. This is an example of: A) Problem solving B) Previous experience C) Clinical practice guideline D) Scientifically based clinical judgment

D. Scientifially based clinical judgment The nurse is demonstrating awareness of the effect of insulin, which is to lower blood glucose level. Because the client will be NPO status for a long period of time, no calories will be consumed. Giving the usual injection of insulin could cause the client to experience hypoglycemia.

As an art, nursing relies on knowledge gained from practice and reflection on past experiences. As a science, nursing relies on: A) Experimental research B) Nonexperimental research C) Physician-generated research D) Scientifically tested knowledge

D. Scientifically tested knowledge As a science, nursing draws on scientifically tested knowledge applied in the practice setting.

A nurse working in a special care unit for children with severe immunologic problems cares for a 3-year-old boy from Greece. The nurse is having difficulty communicating with the father. What is the appropriate action? A) Care for the boy the same as for any other client. B) Ask the manager to talk with the father and keep him out of the unit. C) Have another nurse care for the boy, because maybe that nurse will communicate better with the father. D) Search for help in interpreting and understanding the culture differences by contacting someone from the local Greek community.

D. Search for help in interpreting and understanding the culture differences by contacting someone from the local Greek community Acquiring cultural and language assistance will help the nurse understand the needs of both the father and the son. The other three options are not culturally sensitive or helpful to the client and his father.

The nurse in a diabetic clinic conducts monthly seminars for diabetic clients. During these seminars, the importance of taking insulin as directed to prevent diabetic complications is emphasized. This is considered which level of preventive care? A) Illness prevention B) Tertiary prevention C) Primary prevention D) Secondary prevention

D. Secondary prevention Secondary prevention is prevention geared toward individuals who are already experiencing health problems or illness and who are at risk of experiencing complications or a worsening of their condition

A nurse is going to teach a client how to perform a breast self-examination. Which of the following statements is the behavioral objective that best measures the client's ability to perform the examination? A) The nurse will discuss learning objectives. B) The client will verbalize the steps involved in breast self-examination within 1 week. C) The nurse will explain the importance of performing breast self-examination once a month. D) The client will demonstrate breast self-examination on herself by the end of the teaching session.

D. The client will demonstrate breast self-examination on herself by the end of the teaching session. Option D has a measurable outcome at a specific time. Options A and B do not show that the client has learned to perform the examination. Option C does not show learning.

Which of the following is an example of an appropriately stated learning objective? A) The client will ambulate 100 feet. B) The nurse will explain the importance of a diabetic diet. C) The nurse will demonstrate a sterile dressing change by the end of the first hospital day. D) The client will state three factors that affect cholesterol by the end of the teaching session.

D. The client will state three factors that affect cholesterol by the end of the teaching session. This learning objective includes the required singular behavior, measurable objective, and time frame for completion. Option 1 lacks a time frame for completion and is a behavioral objective. Options 2 and 3 are teaching objectives rather than learning objectives.

A client-centered goal is a specific and measurable behavior or response that reflects: A) The physician's goal for the specific client B) The client's desire for specified health care interventions C) The client's response compared to that of another client with a similar problem D) The client's highest possible level of wellness and independence in function

D. The client' highest possible level of wellness and independence in function A client-centered goal is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. The other options do not meet the definition of a client-centered goal.

Nursing's paradigm includes: A) Health, person, environment, and theory B) Concepts, theory, health, and environment C) Nurses, physicians, models, and client needs D) The person, health, environment/situation, and nursing

D. The person, health, environment/situation, and nursing Nursing's paradigm includes four linkages: the person, health, environment/situation, and nursing.

Evidence-based nursing practice is the end result of: A) Prescriptive theory B) Use of practical knowledge C) Application of theoretical knowledge D) Theory-generating and theory-testing research

D. Theory-generating and theory-testing research The result of theory-generating or theory-testing research is to increase the knowledge base of nursing. As these research activities continue, clients become the recipients of evidence-based nursing care.

Which communication skills is most effective in dealing with covert communication? A. Clarification B. Listening C. Evaluation D. Validation

D. Validation Covert communication reflects inner feelings that a person may be uncomfortable talking about. Such communication may be revealed through body language, silence, withdrawn behavior, or crying. Validation is an attempt to confirm the observer's perceptions through feedback, interpretation and clarification.

The nursing diagnosis 'Readiness' for enhanced communication is an example of which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis

D. Wellness nursing diagnosis The term readiness indicates a wellness nursing diagnosis. An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. A potential nursing diagnosis is a risk for diagnosis.

In order to determine whether an intervention was successful, the nurse evaluates the success of attaining a goal. Which of the following is an example of an evaluation? A) Dressing changed every 8 hours using sterile technique. B) Client will ambulate 500 feet 4 times a day with minimal assistance. C) Client performed quadriceps-setting exercises to right leg every 4 hours. D) Wound filling in with granulation tissue is red to pink without signs of infection.

D. Wound filling in with granulation tissue is red to pink without signs of infection Evaluation occurs after an intervention and indicates degree of achievement of goal attainment. The qualifier "will" indicates that this is a future event and does not evaluate current attainment of goal. Doing an intervention is not evaluating whether it was effective or not.

The type of theory that tests the validity and predictability of nursing interventions is: A) A grand theory B) A descriptive theory C) A prescriptive theory D) A middle-range theory

Prescriptive theory addresses nursing interventions and predicts the consequence of a specific nursing intervention. Middle-range theories are limited in scope, less abstract than grand theories, address specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena. Grand theories are broad and complex.

16. A review of systems (ROS) is based on information obtained from the client during the interview. This information is an example of ______________ data.

Subjective

The nurse asks the client's spouse, "Mrs. Smith, your husband told me that for the past week he has not been eating the meals you prepare. Do you agree?" This is an example of __________________ of assessment data.

Validation

While the nurse is administering flu immunizations in November to a group of older adults at a community senior citizens' center, one of the seniors expresses a fear of contracting the flu from the injection. The nurse reassures the senior that this is not possible because the vaccine contains a dead virus and explains that this injection will produce _________ immunity, in which the senior's body will make antibodies to the virus.

active

The unit policy and procedure manual states that, for all clients admitted to the cardiac unit, if the client experiences chest pain, 1/150 grain nitroglycerin should be administered sublingually and an electrocardiogram should be obtained immediately. This is an example of a(n) _____________.

protocol

Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to a 3 on a 0-10 pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by time of discharge E. Client will be medicated every 4 hours by the nurse

(C) and (D) An outcome goal should be SMART: specific, measurable, appropriate, realistic and timely.

A skin lesion which is fluid-filled, less than 1 cm in size is called: A. Papule B. Vesicle C. Bulla D. Macule

B. Vesicle Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister, chicken pox).